Ms R complained about Hywel Dda Health Board (“the HB”). Her complaint related to treatment that her late father received at Bronglais Hospital (“the Hospital”) in December 2008 and subsequent events. Ms R said that her father was admitted to Hospital after becoming unwell aged 80 years. Among other matters, Ms R complained that the Hospital failed to record important information about his diabetic regime and did not monitor his blood sugar properly. She added that there was evidence to suggest that nursing staff amended the records of her father’s blood sugar monitoring to hide their failures. Ms R explained that sadly her father had a hypoglycaemic attack during the period of poor monitoring, which she believed contributed to a cardiac arrest. Her father died a few months later. Ms R added that the response to her complaint by the predecessor body to the HB and later the HB, was not robust.
The Ombudsman upheld Ms R’s complaint. He concluded that the Hospital did not record and therefore act upon, important details about her father’s diabetic regime and failed to monitor his blood sugar levels properly. The Ombudsman found that the hypoglycaemic attack, to which the Hospital’s failings contributed, had an unspecific causal effect on the patient’s subsequent cardiac arrest and deterioration. The Ombudsman also concluded that there appeared to be a deliberate attempt to cover up the lack of blood sugar monitoring. He found the internal complaint investigations, that took place before his involvement, were inadequate.
The Ombudsman made a number of recommendations to the HB. These included paying Ms R and the family a total of £1700 as an acknowledgement of the uncertainty and distress over how the failings might have contributed to her father’s demise and the extensive time that they had spent pursuing the complaint. He also recommended various systemic reviews, audits and training. The HB undertook to implement his recommendations.
A copy of the full report can be downloaded below.