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Mrs A’s daughter, Sarah, was born with severe developmental delay and throughout her life had complex health care needs. Mrs A complained to the Ombudsman about Sarah’s treatment and care at the Royal Glamorgan Hospital upon her transition from children’s to adult hospital care. Mrs A said that during Sarah’s only admission to an adult hospital ward, there were unacceptable delays in administering the appropriate antibiotic medication and that staff were not trained or equipped to meet Sarah’s needs because of a lack of co-ordination between services during the transfer of her care. Sadly, Sarah died in hospital on 21 October 2009, aged 20. Mrs A believed that the outcome of her final hospital admission would have been different had Sarah’s treatment and care been satisfactory.

The Ombudsman found that arrangements for Sarah’s transfer of hospital care were inadequate. There was no evidence either of a clear, co-ordinated transfer process or of an effective hand over of care. The Health Board also failed to plan and deliver services in a way that recognised Sarah’s individual needs in accordance with the equalities legislation. Whilst the Ombudsman did not find that the poor transition arrangements contributed to any clinical failing, there was some evidence that the quality of Sarah’s care was compromised as a result. The Ombudsman also found that aspects of Sarah’s clinical treatment fell below a reasonable standard; the most significant of which were the failure to initiate treatment with intravenous antibiotics within four hours of Sarah’s admission to hospital and a further delay of more than 21 hours during which two doses of prescribed oral antibiotics were not given. The Ombudsman was unable to say whether or not the outcome would have been different for Sarah but for those clinical failings. Finally, the investigation identified that there were inadequacies in the Health Board’s handling of Mrs A’s complaint.

The Ombudsman upheld each element of Mrs A’s complaint and made a number of recommendations to the Health Board for further action to address the failings identified. The Health Board agreed to implement the recommendations and to apologise and make a redress payment to Mrs A of £2000 in recognition of the failings in her daughter’s care and the resulting uncertainty over the sad outcome.

The full report can be downloaded below.