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Mrs J, the daughter of the late Mrs Y, complained to Cwm Taf Health Board about the clinical investigations and treatment provided to her mother when she attended the Accident & Emergency Department on 13 May, and the Medical Day Unit at Royal Glamorgan Hospital on 14 May 2010. Sadly, Mrs Y died following her discharge on 16 May 2010. Pulmonary thromboembolism was recorded as the principal cause of death.

Mrs J complained that the clinicians treating her mother failed to take timely and appropriate action in response to a blood test result which indicated thrombosis. Mrs J considers that had prompt action been taken when the result was available on 14 May 2010, her mother’s death may have been prevented.

The Ombudsman’s investigation found that the test was viewed by a nurse before Mrs Y’s discharge on 14 May. Mrs Y’s blood result was positive. A positive result can indicate thrombosis. The test result does not appear to have been appropriately considered, if at all, by the doctor who made the decision to discharge Mrs Y or by the Consultant with overall responsibility for her care before her discharge.

The Ombudsman concluded that the failure to consider and act upon the positive blood test result before making the decision to send Mrs Y home fell below an acceptable standard of care. This failing gave rise to a missed opportunity to make the correct diagnosis and to treat Mrs Y appropriately. The treatment that should have been given might have prevented her death. The investigation also identified a number of additional failings on the part of the Health Board.

The Ombudsman upheld the complaint and recommended that the Health Board should provide explanations and an apology to Mrs J and her family in addition to a redress payment of £ 5,000.

A copy of the full report can be downloaded below.