Mrs D complained about the treatment her late father, Mr A, received at the Royal Glamorgan Hospital (“the Hospital”) in 2007 and 2008. At that time, the Hospital was the responsibility of the former Cwm Taf NHS Trust (“the Trust”). Due to NHS re-organisation in Wales during 2009, the obligations of the former Trust now lie with the Cwm Taf Local Health Board (“the LHB”).
Mrs D said that the Hospital did not properly investigate, diagnose or treat Mr A, during two admissions in late 2007 and early 2008. The admissions were soon after Mr A had received successful surgery and radiotherapy to treat a rectal tumour. They resulted from general but undiagnosed ill health. Mr A sadly died in January 2008, whilst in the Hospital, due to shock caused mainly by a gastric ulcer. Mrs D stated that the Hospital did not diagnose that Mr A had a pelvic abscess during his first admission, noting that his post mortem concluded that this was a contributory factor in his death. She maintained that during the second admission, the gastric ulcer should have been identified and treated. She also complained that a drug had not been administered properly. Mrs D also expressed dissatisfaction with the Trust’s complaint handling. She asserted that the former Chief Executive should not have signed the complaint response, as a clinician involved in Mr A’s care was a close relative of hers. Mrs D also said that the Trust’s complaint response to her mother, did not deal with all the issues.
The Ombudsman did not uphold the complaint about the first admission. However, he found serious failings with regard to the second admission. He found that there was no systematic approach to diagnosing Mr A’s condition, no plan about when clinical reviews should take place and no decision made about the frequency that nursing staff should record observations for Mr A. In the event, a doctor did not review Mr A the day before his death and observations were not sufficient or carried out properly. Had those failings not occurred, the problem with Mr A’s undiagnosed gastric ulcer might have come to light. The Ombudsman concluded that there was a chance that had that happened, the sad outcome might have been different. The Ombudsman also found that Mrs D was right about the poor administration of a drug. He concluded that the former Chief Executive should not have signed the complaint response without informing the family of the connection between her and a clinician who had been involved in Mr A’s care, even though that clinician was not criticised in his report.
The Ombudsman made numerous recommendations to the LHB, which it has accepted. These included paying £1500 to Mrs D as an acknowledgement of the uncertainty she has to live with concerning whether her father might have survived the episode with better care; providing evidence that effective systems are in place regarding nursing observations; carrying out an audit to ensure that patients requiring daily clinical reviews are receiving them and introducing a written conflict of interest policy.
The full report can be downloaded below.