North Wales patient death following "substandard care"

Reporter:

Dale Spridgeon

THE care of a patient has been branded ‘substandard’ by the Public Services Ombudsman for Wales following his death at Ysbyty Gwynedd in Bangor.

The patient’s daughter, identified only as Ms C, who works for Betsi Cadwaladr Health Board handling complaints, complained to the Ombudsman after staff missed several opportunities to identify and prevent a deterioration in the condition of her father – named only as Mr D – which led to him suffering a fatal cardiac arrest.

Mr D was admitted to hospital in December 2014 with a chest infection. He suffered with chronic obstructive pulmonary disease and was diagnosed with pneumonia and respiratory failure.

His National Early Warning System (NEWS) observation test score should have prompted his transfer to a high dependency unit but there was delay in finding Mr D a bed and he was not seen by a consultant until the following morning.

A day later Ms C was informed that Mr D was improving and discharge plans were discussed. However, his condition worsened over the next 24 hours and his medical records indicated he had acute kidney injury, secondary to sepsis, but this was never treated.

On Christmas Day, four days after admission, Mr D suffered a cardiac arrest and died. Ms C complained to the health board in February 2015. Almost a year later she had still not received an update and she sought the help of a community health council advocate.

During this time Ms C claimed a Betsi Cadwaladr employee involved in her father’s care made inappropriate comments about the complaint to a family member; the health board failed to follow this up properly.

Nineteen months after receiving the original complaint, the health board sent its response, admitting failing to carry out key observations and incorrectly calculating Mr D’s NEWS score, it claimed that these did not affect the outcome. The Ombudsman, Nick Bennett, found a number of serious failings, including: missed opportunities to take action which might have prevented Mr D’s deterioration and subsequent death, inaccurate recording of the cause of Mr D’s death and failure to carry out a serious incident report, despite this being referred to in the complaint response.

Mr Bennett said: “I find it extremely concerning that the health board refuse to admit that had they approached Mr D’s care differently, his death could have been prevented.

“Not only was the care substandard in this case, I find the health board comments disingenuous and indicate an unwillingness to accept the seriousness of the situation.

“Furthermore the cause of Mr D’s death was wrongly recorded, causing even more distress to the family, which is unacceptable.

“The fact that a member of its own staff, accustomed to the concerns process, found the health board’s approach to her complaint so frustrating that she was forced to seek assistance from an advocate, does not instill confidence for members of the public using the system. I urge the health board to learn from this case and address the serious clinical failings. By doing so, I hope that patients requiring critical care will not be overlooked in the future.”

Email:

dale.spridgeon@nwn.co.uk

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