Ms X complained about the care and treatment provided to her late brother, Mr Y, during two admissions to Prince Charles Hospital (“the Hospital”) in April 2015. Ms X complained about whether it had been clinically appropriate to discharge Mr Y following his first admission. Ms X was also concerned about the care provided to Mr Y during his second hospital admission and whether any action could have been taken to prevent Mr Y’s bowel from perforating and sepsis developing, from which Mr Y sadly did not recover.
The Ombudsman found that the decision to discharge Mr Y following his first admission was reasonable and did not uphold this element of the complaint. During Mr Y’s second hospital admission, the Ombudsman found that there were a number of shortcomings in the care and treatment provided which fell well below reasonable standards. The response to Mr Y’s deterioration was highly unsatisfactory and sepsis should have been recognised and treated earlier. A severe complication of colitis (dilation of the colon) was not identified promptly which led to the perforation of Mr Y’s colon and critical illness. This was a significant failing and clearly Mr Y should have undergone surgery sooner. The Ombudsman found that the delay significantly increased the likelihood of a poor outcome. The shortcomings in the identification and treatment of sepsis also increased the risk to Mr Y. The Health Board agreed with the Ombudsman’s finding that Mr Y should have undergone surgery sooner which would have increased the chance of a more positive outcome for Mr Y. The Ombudsman upheld these complaints and recommended that the Health Board:
(a) Write a letter of apology to Ms X for the significant shortcomings in Mr Y’s care.
(b) Provide financial redress of £4,500 to Ms X in respect of these shortcomings and the injustice caused to Mr Y in that he did not receive adequate treatment for the suffering he endured. This represents an injustice to Ms X and her family who will now have to live with the uncertainty of knowing that, had Mr Y received adequate treatment, it
would have increased his chances of survival and in recognition of the real uncertainty which remains as to whether the outcome for Mr Y could have been different if Mr Y had undergone surgery sooner.
(c) Ensure that arrangements are in place for patients with severe colitis to be managed via a multidisciplinary approach with involvement and leadership by consultant gastroenterologists and consultant colorectal surgeons.
(d) Provide training for ward staff in communication with family and carers of vulnerable patients with a history of mental illness and of appropriate care pathways for such patients.
(e) Discuss the contents of this report with the Consultant Surgeon to emphasise the importance of providing clear and accurate information to complainants during Health Board investigations.
(f) Carry out an audit to ensure that the management of sepsis by medical staff is in line with national requirements and includes a protocol for escalation and clear care pathways.
(g) Carry out an audit to ensure that there is adequate consultant (physician and surgical) cover for gastroenterology patients at all times.
The Health Board agreed to implement these recommendations.