Ms P complained that her late mother, Mrs P, was inappropriately discharged home from Bronglais Hospital in Aberystwyth in February 2008; that communication with her about her mother’s condition was poor; and that the Health Board did not robustly investigate her complaints or provide her with a reasonable and timely response. Sadly, Mrs P died within hours of being discharged home.
The Ombudsman found that Mrs P had suffered marked falls in her oxygen saturations (a measure of respiration efficiency) during the two nights before she was discharged. While the first fall was reported to the doctors the next day, there was no evidence that they were notified of the second fall, or that other abnormalities in Mrs P’s pulse and blood pressure were recognised or acted on. The Ombudsman concluded that given Mrs P’s abnormal observations, she should not have been discharged when she was. The Ombudsman also found that communication with Ms P about her mother’s condition was poor, in part because of the failure to recognise the abnormal observations. The Ombudsman upheld these parts of Ms P’s complaint.
Turning to the handling of Ms P’s complaint, the Ombudsman was concerned that the process became protracted, and that there were some unavoidable delays. He also noted that the Health Board’s internal investigations had not identified any concerns about the lack of response to Mrs P’s abnormal observations. The Ombudsman also upheld this complaint.
The Ombudsman recommended that the Health Board apologise to Ms P and pay her £100 in recognition of the time and trouble she had been put to in pursuing her complaint. He also made recommendations aimed at improving responses to abnormal observations and record keeping on the ward concerned. The Health Board has agreed to implement the Ombudsman’s recommendations.
The full report can be downloaded below.