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Mrs X complained to the Ombudsman about the care her father Mr Y received at the Royal Gwent hospital between Friday 5 December 2014 and over the following weekend after his admission suffering with constipation. Mr Y died on 8 December. Mrs X complained her father’s raised blood glucose levels were not managed and he was not seen by a doctor for several hours. Mrs X said that despite her father having a full care package in place at home, he remained on an unsuitable ward and had an undignified end of life. Mrs X also complained that the Aneurin Bevan University Health Board’s (“the Health Board”) investigation of her complaint had been unhelpful.

The Ombudsman upheld Mrs X’s complaints. He found that no action was taken in relation to Mr Y’s elevated blood glucose levels over the weekend. Further, nursing staff had not informed the medical team of Mr Y’s aspiration or fluctuating swallowing ability (dysphagia). He was not referred to a Speech and Language Therapist (“SALT”) and he had not been kept nil by mouth (“NBM”) in the interim.

The Ombudsman found that on Sunday, Mr Y’s condition deteriorated and he was not reviewed by a doctor for over six hours. Nursing staff had not escalated the failure of a doctor to attend Mr Y. Consequently, antibiotics were not administered in a timely manner. The Ombudsman could not be certain whether earlier intervention might have led to a different outcome for Mr Y. The Health Board had not recognised that Mr Y had a full care package in place at home, and he had been placed on an inappropriate ward.

The Ombudsman did not uphold Mrs X’s complaint about her father’s end of life on an open ward. Side rooms were in use by patients with priority need.

The Ombudsman found that the Health Board’s own investigation of Mrs X’s complaint did not identify the failings in Mr Y’s care.

In addition to a number of steps it was already taking, the Health Board agreed to implement the following recommendations:

a) apologise to Mrs X for the identified failings and, in recognition of the distress and uncertainty associated with her father’s care, make a financial redress payment of £2000 to her

b) remind all nursing staff that patients with dysphagia should be referred without delay to SALT and kept NBM until formally assessed

c) review – with Educational Diabetic Nurse input – whether there are training issues for nursing staff on this ward in relation to the identification and management of hyperglycaemia

d) (i) establish why escalation procedures were not followed in this case

(ii) review the escalation process, in light of the outcome, to ensure it will be more effective in the future.

A full copy of the report is available below.