A VULNERABLE man choked to death after Gwynedd health body care failings a report has found.

The Public Services Ombudsman for Wales says there were failures to “undertake the appropriate risk assessment” and “produce an acceptable plan” for his care.

The three bodies concerned have all apologised to the man’s family and the Ombudsman Nick Bennett says it is hoped that “lessons have been learned” from the multiple failings.

An investigation followed a complaint over the care of anonymous man, ‘Mr N,’ between 2015 and his death in March 2017, by Gwynedd Council, Betsi Cadwaladr University Health Board and Cartrefi Cymru.

Mr N suffered from drug-induced psychosis and a severe brain injury. He required round-the-clock care. When he died, he was living in a rented home with 24-hour care provided by by Cartrefi Cymru, funded jointly by the council and health board.

The Ombudsman found no documentation relating to the awarding of the care contract to Cartrefi Cymru, or specific terms relating to Mr N’s care needs and the respective responsibilities of all parties involved.

There was also “maladministration” on the part of the council and health board and no documentation showing the council, as lead commissioner, was monitoring the delivery of care.

It was also found that Cartrefi Cymru failed to undertake a comprehensive assessment of Mr N’s choking risk.

He had been hospitalised following an episode in 2016, and problems with chewing and swallowing were recorded in 2015.

Nick Bennett, Public Services Ombudsman for Wales, said: “I am extremely concerned at the multiple failings in communication between the three bodies involved in providing care to Mr N.

It’s impossible to say with any certainty whether any of the bodies involved had seen a risk assessment relating to the risk of him choking, but given his obvious vulnerabilities, it was clear to me that the care provider should have carried out its own risk assessment at the earliest opportunity.

“While I cannot conclude whether any of the failings I have identified caused or contributed to Mr N’s death, his family have been left with the uncertainty that, were it not for these failings, things might have been very different. I sincerely hope lessons are learned from this tragic case.”

The Council and BCUHB have agreed to recommendations, including: apologising to Mr N’s family for the failings identified in the report and reviewing their respective contract governance arrangements to ensure they are in line with best practice as set out in the Wales Procurement Policy Statement.

Cartrefi Cymru has agreed to provide refresher training for staff on the importance of reviewing care packages and carrying out appropriate risk assessments as soon as they are contracted to provide care to an individual.

Gill Harris, Betsi Cadwaladr University Health Board’s Deputy Chief Executive and Executive Director of Nursing and Midwifery, said: “We wholeheartedly apologise for the failings identified by the Ombudsman and we have already begun the process of working with Gwynedd Council and Cartrefi Cymru to act on his recommendations.”

A Gwynedd Council spokesperson said: “We accept the findings and recommendations made by the Ombudsman following his investigation and will implement them in full.

“The Ombudsman’s finding that the contractual arrangements relating to Mr N’s care were unclear and in need of review and improvement is accepted.

“Although the Ombudsman did not find that this contributed to the tragedy it remains a matter where there were failings. We have written to Mr N’s family to apologise for the additional distress this has caused.”

Cartrefi Cymru statement: “We welcome and fully accept the findings and recommendations made by the Ombudsman (as we made clear to him when we had an opportunity to consider his draft report prior to publication).

“This follows his investigation into the tragic death of Mr N. The Ombudsman accepted entirely the Coroner’s verdict that this was a tragic accident, and repeats the praise for the prompt actions of Mr N’s support worker on the night.

“However, the report highlights that the documentation relating to Mr N’s care was in need of review and improvement, and although, importantly, the Ombudsman did not conclude that this was a factor in Mr N’s death, it is rightly described as a failing on the part of all the agencies involved.

“We accept this judgement and, for our part, we would like to apologise to Mr N’s family for the additional distress this failing has caused. We can also confirm that since Mr N’s death, the need for prompt reviews of care documentation has been reinforced throughout all our services.