A cancer patient died after a health board provided her with a “very poor standard of care”, the Public Services Ombudsman for Wales has found.
The ombudsman launched an investigation after receiving a complaint about the care given to Mrs X (anonymised) in December 2019 by Cwm Taf Morgannwg University Health Board.
He found that a “catalogue of failings” led to the health board failing to diagnose pneumonia in the patient for an “alarming” 12 hours leading to a “significant delay” in administering appropriate treatment. As a result Mrs X died the day after her admission to Prince Charles Hospital in Merthyr Tydfil.
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He also found that a 15-hour delay in administering antibiotic treatment, during which Mrs X was nursed in a hospital corridor, led to her untimely and “avoidable” death.
In addition the investigation found that there was a “considerable delay” in administering oxygen, even when Mrs X’s oxygen saturation levels were recorded as low, which may have contributed to the aspiration that caused her death.
Furthermore the ombudsman’s report found that Mrs X’s care was “compromised” due to being nursed in the corridor of an over-capacity emergency department. The report also found that pressure in the emergency department, and low staffing levels, may have contributed to the poor care that Mrs X received.
The ombudsman also criticised shortcomings in the health board’s response when Mrs X’s husband complained about his wife’s treatment. By failing to thoroughly investigate Mr X’s complaint until the ombudsman launched his investigation he found that the health board contributed to a prolonged ordeal for Mrs X’s family which was “distressing and potentially unnecessary”. He found that that this resulted in a delay in identifying the “serious shortcomings” in Mrs X’s care and vital lessons being learned.
Commenting on the report Nick Bennett, Public Services Ombudsman for Wales, said: “This is a distressing case where the catalogue of failings I have identified contributed to a very poor standard of care for Mrs X and denied her the opportunity to spend the little time she had left with her family. This deeply saddens me and I wish to convey my heartfelt condolences to Mr X and the family.
“My report has identified several areas where the care received by Mrs X fell far below what she and her family should have expected. There were several serious service failures in this case and the consequent injustice to Mr X and her family is immeasurable.
“Not only did Mrs X not receive a timely diagnosis or appropriate treatment but the failure to do so had a fatal outcome in this tragic case.”
Cwm Taf Morgannwg University Health Board has agreed to several recommendations including:
- Providing awareness training for all emergency department staff on the correct use of the National Early Warning Score (NEWS) system – a tool developed to improve detection and response to clinical deterioration in adult patients.
- Carrying out an audit of a sample of patient records to ensure that staff have escalated appropriately where required.
- Providing a full written apology to Mr X for the significant failings in his wife’s care and the distress caused to the family, which meant that they were denied what little time they had left with Mrs X.
Paul Mears is the new chief executive of Cwm Taf Morgannwg University Health Board
(Image: Cwm Taf Morgannwg University Health Board)
Paul Mears, CEO of Cwm Taf Morgannwg UHB, said: “We would like to offer our sincere apologies to the family of Mrs X for the failures in care and the distress they have experienced and to convey our condolences on their very sad loss.
“This is a deeply tragic and distressing case and our own internal investigations, alongside today’s ombudsman report, show that there were clearly areas in which the care provided to Mrs X fell short of the standards expected.
“We are committed to learning lessons from these very sad events and an action plan has been put in place to ensure the shortcomings are addressed and improvements are made to our services. We have also recruited additional staff to the department and increased the baseline number of staff in certain specialities on shift. We will continue to work with our teams to identify and put in place further improvements and implement the ombudsman’s recommendations in full.”
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