North Wales patient suffered 'avoidable and unnecessary' pain

The dignity of the 60-year old female wheelchair user who had bowel care needs was also “compromised”.

It came amid findings that Betsi Cadwaladr University Health Board “failed” to deliver appropriate medical and nursing care.

The Public Services Ombudsman for Wales issued a public interest report today  following an investigation and a hospital health boss has “sincerely apologised” for distress caused.

The patient, who had long-standing health conditions and needed regular care from a nursing team sadly died in May, 2020.

The issue came to light after a Mrs A complained about the hospital care her sister Ms B had received from Betsi Cadwaladr UHB, at Ysbyty Glan Clwyd, between May 2019 and May 2020.

Mrs A was concerned over delays in kidney treatment her sister had received. She also complained about inadequate bowel care when she was admitted to the hospital with breathing problems in April and May 2020.

Ms B had not received the care as no skilled staff were available. Nursing staff had also not updated doctors that it had not been done.

Ms B developed new symptoms suggesting a bowel blockage but she was discharged without the symptoms being considered.

Mrs A complained to the health board about the failings but was unhappy with its response.

The Ombudsman found that Ms B’s kidney treatment was “reasonable.”

However, she was “very concerned” that Ms B did not receive the right bowel care and was discharged home without being seen by a doctor after developing new symptoms.

The Ombudsman also found that the health board’s own investigation into Mrs A’s complaint was not thorough or open enough.

Record keeping by the health board also fell short of the requirements expected for doctors and nurses.

Public Services Ombudsman for Wales, Michelle Morris, said: “I would firstly like to offer Mrs A and her family my sincere condolences. I recognise that they will find much of the detail in this report distressing.”

“It is clear from my report that there were shortcomings in medical and basic nursing care received by Ms B.

“I am concerned that although Ms B herself and Mrs A clearly informed the nursing staff of Ms B’s bowel care needs, that was not given the attention that it should have had – particularly given the possible serious medical consequences of not doing so.

“We cannot say for sure that the fact that Ms B did not receive the bowel care she needed contributed to her death, as she was very unwell with other problems.

“However, I have no doubt that the failings I have identified caused her avoidable and unnecessary pain and discomfort as well as compromised her dignity.”

“Ms B was in hospital during the early days of the COVID-19 pandemic.

“We understand and acknowledge that these were difficult and uncertain times with stretched NHS resources. However, Ms B’s care was simply not of an acceptable standard.

“The NHS in Wales is now bound by statutory Duty of Candour, requiring them to be open and honest with patients and service users when things go wrong.

“In my view, the initial review of Ms B’s care undertaken by the Health Board lacked depth, rigour, openness and transparency required by that Duty.

“I am also very concerned that my office has identified similar problems of failings in basic nursing care, in record keeping, and in communication in previous cases we have investigated about this hospital.”

The Ombudsman recommended that Betsi Cadwaladr University Health Board should provide an apology to Mrs A and pay her £4,500 for distress and having to pursue her complaint

It also recommended it should: share her report with staff involved, to reflect on their actions, remind nursing staff about proper record-keeping, complete a Bowel Care Protocol, and take steps to ensure that nursing and medical staff at the hospital are trained to carry out manual bowel evacuation procedure, and review its complaint handling and responses in light of the NHS Wales Duty of Candour which will be introduced in April, 2023.

The Health Board has accepted the Ombudsman’s recommendations.

Dr Nick Lyons, Betsi Cadwaladr University Health Board’s interim deputy CEO and executive medical director, said: “I would like to sincerely apologise again to this patient’s family for the distress caused both during her treatment and the period of their complaint.

“We acknowledge the Ombudsman’s report, accept all the recommendations in full and have made sure the lessons contained within it have been made clear to all staff involved.

“We can only gain the trust of the public we serve by being completely transparent about failings when they occur – and we are fully committed to that principle.”