Mrs R raised concerns about the care her late mother, Mrs T received from Abertawe Bro Morgannwg University Health Board which, since the time of the events has changed its name to Swansea Bay University Health Board (“the Health Board”).  Mrs R complained that on 26 and 27 June 2017 the Health Board failed to take prompt and appropriate action to assess and treat Mrs T’s symptoms of a stroke.  She also complained that during Mrs T’s consequent admission to hospital, the Health Board failed to ensure adequate monitoring and care of Mrs T’s fluid balance and nutritional needs, take prompt and appropriate action to investigate the cause of Mrs T’s distended abdomen and bowel symptoms, and manage Mrs T’s anxiety.

The Ombudsman found that there was no appropriate assessment of Mrs T’s risk of a stroke, even when her family raised concerns that she appeared to have a left-sided weakness, facial droop and slurred speech.  Furthermore, when doctors were asked to review Mrs T in light of her family’s concerns on the 26 and 27 June, two separate clinicians failed to document their attendance, their assessment or their findings and a third noted no reference to whether any symptoms of potential stroke were considered.  By the time Mrs T’s stroke was diagnosed on the afternoon of 27 June it was too late to administer thrombolytic medication, although it was not possible to say for certain whether this would have limited the damage caused by the stoke or reduced Mrs T’s resulting disabilities.

The Ombudsman also found that there were further shortcomings in record keeping throughout the period of care.  This made it impossible to determine what food and drink Mrs T consumed and suggested that her fluid balance was unregulated.  The Ombudsman concluded that Mrs T was probably malnourished given her significant weight loss during her admission.  However, this was not appreciated or addressed because of omissions and errors in the records and Mrs T was not referred to a dietician until 3 weeks after she should have been.  It was unclear whether these shortcomings resulted in a significant impact on Mrs T’s clinical condition, but they led to worry and frustration for Mrs T’s family, who saw that she was not eating and was rapidly losing weight, and to uncertainty as to whether Mrs T’s nutritional deficit might have compounded her other symptoms.
The Ombudsman considered that the Health Board took appropriate action to investigate Mrs T’s bowel symptoms during her admission.  Whilst no specialist advice was sought from a Gastroenterologist, which might have been helpful, it was unlikely that her treatment or management would have been any different even if such a referral had been made.  There was no indication that specialist input or investigation was required until 22 August, when Mrs T dramatically deteriorated.  However, by the time Mrs T was taken for a stomach X-ray on 23 August, Mrs T was critically unwell.  The Ombudsman found there was a failure to reconsider whether to proceed with the X-ray given Mrs T’s deterioration and sadly, as Mrs T was being returned to the ward after the X-ray, she died.

Finally, the Ombudsman found that Mrs T experienced severe and prolonged anxiety and was probably suffering from delirium during her admission.  The treatment she received for this was, overall, appropriate and the decision not to prescribe ongoing sedatives was acceptable clinical practice, because Mrs T was at high risk of breathing difficulties.  However, he felt that specialist input should have been sought.  This might have provided some reassurance to Mrs R, who felt that her concerns and her requests for more to be done were being dismissed and ignored.  Furthermore, a specialist should have been able to suggest whether there was any other type of medication or intervention available to alleviate Mrs T’s anxiety without the associated risks of a sedative.

The Health Board agreed to the Ombudsman’s recommendations that, within one month of the date of his report, it should:

a) ensure that all clinicians involved in Mrs T’s care have the opportunity to consider the findings in this report and demonstrate that those individuals whose actions have been criticised have reflected on how they can improve their practice in future

b) remind all doctors in the Emergency Department and the Medical Assessment Unit of the First Hospital of the importance of documenting their attendance and assessment of patients, as well as any examination findings and outcomes

c) demonstrate that it has appropriate processes in both the First and Second hospitals to enable ward staff to access specialist input from other specialities

d) apologise to Mrs R for the failings identified in this report.

The Health Board agreed to the Ombudsman’s recommendations that, within three months of the date of his report, it should:

e) provide evidence that it has adopted an appropriate, recognised stroke risk assessment scoring system and taken action to ensure that all doctors in the Emergency Department, Medical Assessment Unit and the stroke ward of the First Hospital have been informed and trained on how to apply it

f) review the training records of all doctors in the Emergency Department, Medical Assessment Unit and the stroke ward of the First Hospital, and provide refresher training to those whose training is not up to date on the recognition and treatment of TIAs and stroke, with particular reference to the most recently published NICE guidance

g) carry out a random sampling audit of patients’ nursing records on the stroke wards of both hospitals, with a particular emphasis on completion of nutrition and fluid balance charts, and take action to address any identified trends or shortcomings.