Mrs X complained about the care and treatment her late husband received from Hywel Dda University Health Board’s (“the Health Board”) out of hours service (”OOH”) and Welsh Ambulance NHS Trust (“WAST”) during the final stages of his life.
The investigation found that the Health Board had failed to ensure that there would be any OOH GP cover in the Pembrokeshire area on 15 July 2013. As a result of that failing Mr X had to wait three hours to be seen by a doctor, which is a significant period when experiencing pain and anxiety, particularly in the final hours of life. The failure to ensure adequate cover was in place put additional strain on the emergency services and placed the residents of Pembrokeshire at risk.
The investigation also found that following Mr X’s sad death, the paramedic in attendance did not understand his responsibility under the “Recognition of Life Extinct” (“ROLE”) policy which resulted in an unnecessary decision to call the Police. It was also noted that in response to Mrs X’s complaint about this matter WAST endorsed the actions of the paramedic despite those actions being contrary to the ROLE policy.
It was recommended that the Health Board apologise to Mrs X and her family and pay the sum of £1000 in recognition of the distress and injustice arising from the identified service failure. It was also recommended that the Health Board remind GPs of the need to ensure that a patient’s computerised “special notes” are completed and accessible by the OOH service and that “Just in Case Boxes” contain the necessary prescriptions. Finally it was recommended that the Health Board review its contingency plan for periods where there are no GPs available in the area and ensure that the OOH practitioners available have the necessary skills.
It was recommended that WAST apologise to Mrs X and her family and pay the sum of £500 in recognition of the distress and injustice arising from the identified service failure. It was also recommended that paramedics and officers are reminded of their responsibilities under the ROLE policy and the Code of Practice. Finally it was recommended that WAST review its training plan to include training on the ROLE policy.
A full copy of the report is available below.