Download Ask for: James Merrifield 01656 644 200 13 July 2012 Mrs Mary

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Ask for: James Merrifield
01656 644 200
13 July 2012
[email protected]
Mrs Mary Burrows
Chief Executive
Betsi Cadwaladr University LHB
Ysbyty Gwynedd
Penrhosgarnedd
Bangor
Gwynedd
LL57 2PW
Dear Mrs Burrows
Annual Letter 2011/12
Following the recent publication of my Annual Report, I am pleased to enclose
the Annual Letter (2011/12) for Betsi Cadwaladr University Health Board.
The Annual Letter provides you with a clear and concise breakdown of all
complaints received and investigated by my office during 2011/12 in relation to
your Health Board. You will also find details of the time taken by your Health
Board in responding to requests for information from my office, as well as
summaries of all reports issued in relation to your Health Board.
As outlined in my Annual Report, the total number of maladministration and
service failure complaints received by my office increased by 13% compared with
2010/11. Health complaints continue to be the most numerous type of complaint
and account for almost a third of all complaints received. There was also an
overall increase in the number of complaints taken into investigation by my office.
Whilst this trend will have been influenced by the NHS Redress Measure which
came into force on 1 April 2011, I also believe that people are increasingly
inclined to complain about poor service in the NHS.
It is pleasing to note the increased levels of ‘Quick Fixes’ and ‘Voluntary
Settlements’ which would not be possible without the cooperation of public
bodies. This means that it has been possible to increase the number of
complaints closed at earlier stages without the need for a full investigation (where
it is clear that there are no systemic issues associated with the complaint).
Nevertheless, my office has had reason to issue a number of Public Interest
Reports during 2011/12 which raised serious concerns and failings. Many of
these relate to health complaints, and I would encourage all health boards to
revisit these reports, which are available on my website, to ensure that the
lessons are learnt. The other public interest reports could also have general
learning opportunities for health bodies.
I raised concerns in last year’s Annual Letters regarding the amount of time taken
by public bodies in Wales in responding to requests for information from my office
and it is disappointing that this situation has not improved. The statistics for
2011/12 show that average response times for health bodies, as well as other
bodies, in Wales has worsened to the extent that roughly three quarters of
responses are received more than four weeks after they were requested. I
continue to urge all Welsh public bodies to assist my staff in progressing their
investigations by providing responses in a timely manner. The response times for
your Health Board indicate a pressing need for improvement.
In reference to the performance of your Health Board, the figures indicate that the
number of complaints received by my office has increased by more than a third in
comparison to the figures for 2010/11. Consequently, my office has also taken
more complaints into investigation in comparison to 2010/11, although this figure
remains below the Health body average.
The figures indicate that complaints relating to ‘Clinical treatment in hospital’
remain by far the largest, and are also in excess of the Health body average. It is
pleasing to note the large number of outcomes using Quick fix or Voluntary
settlement, which is also in excess of the figure which could be expected for your
Health Board. However, it should also be noted that my office had reason to
issue a Public Interest Report in relation to one complaint.
I have copied this correspondence to the Chair of your Health Board with the
intention that it be considered by the Board. I would also welcome the opportunity
to meet with you and the Chair of the Board, and my office will be in contact
shortly to make arrangements. Finally, a copy of this letter will also be published
on our website.
Yours sincerely
Peter Tyndall
Ombudsman
Copy: Chair, Betsi Cadwaladr University Health Board
Appendix
Explanatory Notes
Sections A and B provide a breakdown of the number of complaints against Betsi
Cadwaladr UHB which were received and taken into investigation by my office during
2011-2012.
Section C compares the number of complaints against Betsi Cadwaladr UHB which
were received by my office during 2011-2012, with the average for health bodies
during this period. The figures are broken down into subject categories.
Sections D and E compare the number of complaints against Betsi Cadwaladr UHB
which were received and taken into investigation by my office in 2011-2012, with the
average for health bodies (adjusted for population distribution1) during the same
period.
Section F compares the complaint outcomes for Betsi Cadwaladr UHB during 20112012, with the average outcome for health bodies during the same period. Public
Interest reports issued under section 16 of the Public Services Ombudsman (Wales)
Act 2005 are recorded as ‘Section 16’.
Section G compares Betsi Cadwaladr UHB’s response times during 2011-2012, with
the average response times for health bodies, and the average for all public bodies
in Wales during the same period. Graph G measures the time between the date my
office issues an ‘investigation commencement’ letter, and the date my office receives
a full response to that letter from the public body.
Finally, Section H contains the summaries of all reports issued in relation to Betsi
Cadwaladr UHB during 2011-2012. In order to assist in measuring performance
during 2011-2012, sections A-G also contain the relevant figures for 2010-2011,
adjusted for population distribution.
1
http://www.wales.nhs.uk/sitesplus/922/home
A:
Complaints received by my office
Subject
Appointments/
Admissions/ Discharge and
transfer procedures
Clinical treatment in
hospital
Clinical treatment outside
hospital
Confidentiality
Continuing care
Medical records/
standards of recordkeeping
Non-medical services
Services for older people
Services for vulnerable
adults
Patient list issues
Regulation and inspection
Complaint-handling
Other
2011-2012
2010-2011
9
4
58
34
4
1
5
4
2
7
1
0
1
0
1
0
1
1
2
1
12
1
0
0
0
7
96
60
TOTAL
B:
Complaints taken into investigation by my office
Number of complaints taken
into investigation
2011-2012
2010-2011
28
20
C:
Comparison of complaints by subject category with average for health bodies
2011-2012
No. of complaints
100
75
Betsi Cadwaladr UHB
58
50
Health body average
35
25
9
4
3
3
1
5
0
6
1
1
1
1
0
1
1
2
1
1
0
1
12
8
0
Appointments /
Clinical
admissions / treatment in
discharge &
hospital
transfer
procedures
Clinical
treatment
outside
hospital
Confidentiality Continuing care
Medical
Services for
records /
older people
standards of
record-keeping
Services for
vulnerable
adults
Patient list
issues
Regulation &
Inspection
Complaint
handling
Other
Subject category
2010-2011
No. of complaints
40
34
30
Betsi Cadwaladr UHB
20
10
Health body average
20
4
4
4
3
7
2
7
6
1
1
0
1
5
0
0
Appointments/
admissions/ discharge
and transfer
procedures
Clinical treatment in
hospital
Clinical treatment
outside hospital
Confidentiality
Continuing care
Subject category
Non-medical services Services for Vulnerable
Adults
Other
D:
Comparison of complaints received by my office with average for health
bodies
125
Betsi Cadwaladr UHB
No. of complaints
100
96
Health body average
94
75
63
60
50
25
0
2011-2012
2010-2011
Complaints received
E:
Comparison of complaints taken into investigation by my office with
average for health bodies
50
Betsi Cadwaladr UHB
No. of complaints
40
30
Health body average
30
28
22
20
20
10
0
2011-2012
2010-2011
Complaints investigated
F:
Comparison of complaint outcomes with average outcomes for health bodies, adjusted for population distribution
2011-2012
No. of complaints
30
26
21
21
Betsi Cadwaladr UHB
21
20
Health body average
20
13
10
11
11
7
7
4
1
2
1
7
2
2
2
0
Out of
jurisdiction
Premature
'Other' cases
closed after
initial
consideration
Discontinued
Quick fix/
Voluntary
settlement
Section 16 Other Report - Other Report Upheld - in
Upheld - in
Not Upheld
whole or in part whole or in part
Withdrawn
Complaint outcome
2010-2011
No. of complaints
30
Betsi Cadwaladr UHB
Health body average
19 19
20
14
11
10
3
3
11 10
9
2
8
7
7
4
1
1
4
1
1
3
0
Out of
jurisdiction
Premature
Investigation
not merited
Quick fix/
Voluntary
settlement
Discontinued
Section 21 Section 21 - Section 21 - not Section 16 upheld
partially upheld
upheld
upheld
Complaint outcomes
Withdrawn
Comparison of Betsi Cadwaladr UHB’s times for responding to requests
for information with average for health bodies and All Wales response
times, 2011-2012
G:
100
Betsi Cadwaladr UHB
80
% of responses
Average HB response time
60
Average All Wales response
time
60
40
33
18
20
4
31
30 30
20
15
16
14 14
7
2 2
3
0 2
0
2
0
0
<1 week
1 to 2 weeks 2 to 3 weeks 3 to 4 weeks 4 to 5 weeks 5 to 6 weeks Over 6 weeks
Response time
H:
Report summaries
Health
Public Interest Reports
October 2011 – Clinical treatment in hospital – Betsi Cadwaladr University
Health Board
Mrs W complained about the care and treatment her husband, Mr W, received whilst
a patient at Ysbyty Gwynedd (the Hospital). Mr W had been admitted to the Hospital
for treatment due to dysphagia (swallowing difficulties) experienced when eating and
drinking. He was discharged but was readmitted four days later due to worsening
dysphagia. Mrs W complained that there was a very poor standard of care provided
to her husband during his admissions which led to deterioration in his condition and,
ultimately, contributed to his death.
Mrs W complained about the following:



that a procedure to stretch Mr W’s gullet did not go ahead as planned due to a
nursing staff error;
that her husband was discharged without having this surgery and once
readmitted, due to his declining health, he was too weak to have the
procedure carried out;
that there was a delay in obtaining a second opinion on her husband’s
condition and arranging a transfer to a specialist hospital.
The Ombudsman upheld the majority of Mrs W’s complaints. The Ombudsman found
that the clinical care provided to Mr W was inadequate as it was insufficiently
intensive and lacked input from his consultant physician. The Ombudsman found
that there were a number of clinical failings which contributed to the health problems
that emerged during Mr W’s readmission. The most significant of these was the
decision to discharge Mr W from the Hospital’s care without carrying out an
oesophageal dilatation (a procedure to stretch the gullet) and the delay in raising its
concerns regarding Mr W’s deteriorating condition with a specialist hospital. The
Ombudsman found that whilst the errors identified were significant, there was no
definitive evidence to conclude that the ultimate tragic outcome could have been
avoided but for those errors. Finally, the Ombudsman found that in general, the
nursing care and management of Mr W was reasonable. However, inadequacies in
some of the nursing records prevented a definitive conclusion from being reached in
respect of the adequacy of care delivered when the tubing attached to his chest
drain became disconnected.
The Ombudsman recommended that the Health Board should reflect on the failings
in the care identified and provide confirmation of the further action taken to address
the inadequacies in its staff awareness of national guidelines in relation to
oesophageal dilatation, the Hospital’s transfer procedures for critically ill patients, the
availability of medical cover over Bank Holiday weekend periods and the insertion of
chest drains. The Ombudsman recommended that a payment of £500 be provided to
Mrs W in recognition of the time and trouble in pursuing her complaint together with
a full apology for the shortcomings in the care provided to Mr W and for the Health
Board’s failure to recognise these failings sooner.
Case reference 201001167
Other reports - Upheld
March 2012 – Clinical treatment in Hospital – Betsi Cadwaladr University
Health Board
Mr J complained about the treatment he received at the A&E Department at Ysbyty
Gwynedd (“the Hospital”) during four presentations. In particular, he complained that
on all occasions he had been subjected to delay and a lack of pain relief. The doctor
he saw (acting as a team leader at the A&E) failed to take an x-ray of Mr J on his first
visit, following a fall he had sustained at home. An x-ray taken on his second visit,
two days later, revealed Mr J had a fracture dislocation of the neck, requiring
immediate immobilisation and transfer for surgery at a specialist neurological centre.
He was fitted with a Halo brace to remain in situ for a number of weeks. 2 Mr J’s third
and fourth visits to the Hospital concerned pain at the pin sites; he had developed an
infection and the pins were loosening (potentially affecting the stability of his neck).
He complained that the doctor he saw cleaned the pins without adopting a sterile
technique and failed to refer him to the neurological centre on request, where he
ultimately had to go to treat the serious infection and deal with the loose pins.
The investigation found that in accordance with clinical guidance, Mr J ought to have
been immobilised and x-rayed at his first visit to rule out a spinal injury. The failure to
do so had placed him at major risk of a catastrophic outcome, and was the catalyst
for failures at subsequent visits he made. Fortunately, he has made a good recovery.
Concerns were raised in particular about the first doctor’s standards and clinical
record keeping. The majority of Mr J’s individual complaints were upheld, and his
care at the first visit in particular found to fall short of what was reasonable. A
number of recommendations were made, including the following: an apology to Mr J
and a time and trouble payment of £500; a clinical audit of the first doctor’s clinical
records; his confirmation of either relevant certification or attendance on the
appropriate advanced trauma course to continue acting as an A&E team leader; and
an audit of the A&E department’s pain relief records to ensure compliance with
relevant guidelines. The UHB ultimately agreed to implement all the
recommendations.
Case reference 201100641
March 2012 – Clinical treatment in hospital – Betsi Cadwaladr University Health
Board
Mrs H complained about the standard of care and treatment provided to her father,
Mr B, by Betsi Cadwaladr University Health Board (‘UHB’). Mr B underwent bowel
surgery but sadly died on 28 July 2010.
The Ombudsman’s adviser acknowledged that maintaining a fluid/protein balance is
critical in patients with Mr B’s chronic pre-existing problems. However, the
Ombudsman was satisfied that staff had acted appropriately to manage Mr B’s
fluid/protein balance.
A Halo brace is a device used to immobilise the head & neck after a cervical fracture. It consists of a
ring attached to the skull by fours pins and supporting rods attached to a vest/jacket.
The Ombudsman found that the overall care provided to Mr B was of a reasonable
standard. He did however identify two shortcomings. Firstly, that the UHB failed to
keep adequate records of Mr B’s fluid input and output. Secondly, that the UHB
failed to monitor Mr B’s nutritional intake and that it failed to provide a timely referral
to a dietician.
The Ombudsman recommended that the UHB send Mrs B a written apology for the
shortcomings identified in the letter report. He also recommended that the UHB take
steps to address the shortcomings identified above.
Case reference 201002586
February 2012 – Clinical treatment in hospital – Betsi Cadwaladr University
Health Board
Mrs A was in pain with her replacement right knee and was referred to Deeside
Community Hospital for x-ray by her GP. The x-ray report said that no complications
were seen. Mrs A was seen privately by a consultant orthopaedic surgeon, and went
on to have a revision knee replacement privately.
The Ombudsman found, after taking advice from a consultant radiologist and
consultant orthopaedic surgeon, that the X ray showed abnormalities which were not
referred to in the report. But Mrs A had arranged a private consultation before
seeing the X ray report. There was no causal link therefore between the identified
shortcomings and her decision to have private treatment and costs which she
incurred. The University Health Board agreed to pay £250 for her time and trouble in
making the complaint. It also agreed to use advice obtained during the course of the
Ombudsman’s investigation about the interpretation of the x-ray for training
purposes.
Case reference 201100249
January 2012 – Clinical treatment in hospital – Betsi Cadwaladr University
Health Board
Mrs Y’s complaint concerned the standard of general nursing care and treatment
provided to her late husband Mr Y at Ysbyty Gwynedd Hospital (“the Hospital”). In
particular she complained about the Consultant Surgeon’s decision to remove Mr Y’s
tumour through open surgery rather than keyhole surgery which had led to
complications. Mrs Y also complained about the Health Board’s failure to answer
how her husband had contracted MRSA and why he was not tested for clostridium
difficile.
The Ombudsman’s investigation found that for clinical reasons keyhole surgery was
not an option for Mr Y, and therefore the Surgeon’s decision to perform open surgery
was appropriate and reasonable. However, in relation to subsequent surgical
procedures, the Ombudsman voiced some criticism of the lack of appropriate
recorded discussion about alternative treatment options available and to that extent
Mrs Y’s complaint was upheld. The Health Board was asked to remind medical staff
of the need to consider and record alternative options.
The investigation found that Mr Y’s nursing notes broadly reflected the good
standard of care he received; although shortcomings were identified in Mr Y’s care in
areas such as pain assessment and risk assessments on falls and Mrs Y’s complaint
was upheld. The Health Board was asked to ensure that procedures were put in
place to prevent similar failings occurring.
However, Mrs Y’s further complaints relating to her husband contracting MRSA and
clostridium difficile were not upheld.
Amongst the recommendations the Ombudsman made were that the Health Board
should provide Mrs Y with a fulsome apology for failings identified in the care of Mr
Y. He also recommended that the shortcomings identified in the report should, as a
part of a wider learning exercise, be discussed at an appropriate consultant’s forum.
Case reference 201001637
December 2011 – Clinical treatment in hospital – Betsi Cadwaladr University
Health Board
Mrs B complained about the care and treatment provided to her daughter by the
Paediatric, A&E and the Ear Nose and Throat (ENT) Departments at Wrexham
Maelor Hospital. Her complaint issues included a failure by the Hospital to diagnose
and treat her daughter with antibiotics for an ear infection and a failure to diagnose a
long standing hydrocephalus. Mrs B also complained about the Health Board’s
delay in responding to her complaint and the failure to communicate information
pertinent to her complaint to her.
The Ombudsman’s investigation concluded that there were shortcomings in the care
provided to Mrs B’s daughter by the A&E and Paediatric Department. He found that
the A&E doctor’s examination of Mrs B’s daughter was inadequate and therefore a
subsequent decision to treat Mrs B’s daughter with Ibuprofen was not reasonable.
Again, the failure by the Paediatric Department to examine Mrs B’s daughter meant
that it was impossible to conclude whether or not her daughter’s hydrocephalus was
longstanding. Mrs B’s complaints were therefore upheld. The Ombudsman did not
uphold Mrs B’s complaint about the ENT Department as he concluded that the
treatment provided was reasonable.
Finally, the Ombudsman found that there were inadequacies in the way the Health
Board dealt with Mrs B’s complaints. Amongst the recommendations the
Ombudsman made were that the Health Board offer Mrs B redress in the form of a
written apology for the shortcomings in her daughter’s treatment identified in the
report. The Ombudsman also recommended a payment of £250 in recognition of the
time and effort Mrs B had expended in pursuing her complaint.
Case reference 201002020
November 2011 – Clinical treatment in hospital – Betsi Cadwaladr University
Health Board area
Dr A complained about the shortcomings in the care and treatment which he
received at Wrexham Maelor Hospital following an elective hernia repair on 31
October 2008. Firstly, he complained that there was a failure to diagnose his
condition whilst he was in hospital and a failure to provide the appropriate response.
Dr A was concerned that he may have received an unnecessary blood transfusion
and that there was a delay in diagnosing that he had suffered a heart attack.
Secondly, Dr A complained that the Consultant Surgeon had refused to provide an
explanation to him about his condition and the treatment provided. Finally, Dr A
complained that there was a failure by the Betsi Cadwaladr University Health Board
to provide a full and satisfactory response to his complaint.
Dr A’s complaint was the subject of two Independent Reviews prior to the
Ombudsman considering his case.
The Ombudsman upheld each element of Dr A’s complaint and recommended that
the Health Board should apologise to Dr A for its shortcomings and confirm the
learning it has taken on board from the clinical issues raised as part of the complaint.
He also recommended that the Health Board should ensure that it had clear
processes in place to allow patients to raise concerns promptly when necessary and
that there are mechanisms in place to monitor the quality of complaint responses.
Finally, he recommended a redress payment of £350 for the time and trouble that Dr
A was put to in pursuing his complaint.
Case reference 201002067
November 2011 – Clinical treatment outside hospital – GP in Betsi Cadwaladr
University Health Board area & Betsi Cadwaladr University Health Board area
Mrs M complained that her late husband’s GP placed an unreasonable emphasis on
his previous history of alcohol consumption when treating him and therefore failed to
diagnose that his liver problems were not alcohol related, but were in fact due to
cancer. Mrs M also complained that her husband was subsequently poorly cared for
in hospital (particularly in respect of personal hygiene) and was discharged when it
was clinically unsafe to do so and without a firm diagnosis. Mrs M complained that
the GP practice failed to properly file the hospital discharge letter, which meant that
the GP was unaware that the hospital suspected extensive cancer and therefore
failed to treat Mr M accordingly.
The Ombudsman found that the GPs assessment of Mr M and the initial diagnosis of
an alcohol related liver complaint was reasonable, given his symptoms and clinical
history. The Ombudsman upheld the complaint about the failure to properly
administer the hospital discharge letter and found that this failing led to an absence
of early palliative care for Mr M.
The Ombudsman found that Mr M’s hospital treatment was, in the main, reasonable,
although he did find some failings. The Ombudsman found that there was a failure to
assess Mr M’s needs in a detailed and comprehensive manner and that this led to a
lack of recognition of his need for assistance in attending to his personal hygiene.
The Ombudsman also considered that communication with Mr M in respect of his
likely poor prognosis was inadequate.
The Ombudsman recommended that each authority should apologise for the failings
identified. He also recommended that the Health Board should include this case in
an external review it had commissioned into recurring themes of service failure.
Case reference 201100251 & 201100252
August 2011 – Clinical treatment in hospital – Betsi Cadwaladr University
Health Board
Mrs M complained about the care given to her brother by the psychiatric liaison
team, following a number of suicide attempts and his discharge from hospital. Sadly
his third suicide attempt was successful.
The Ombudsman found that the assessments of Mrs M’s brother were thorough and
reasonable. He had not been seen by a psychiatrist, but this in itself was not
evidence of service failure, although the UHB had acknowledged that the team
needed closer support from a consultant psychiatrist. But the failure to involve the
family was a shortcoming and there had been confusion about confidentiality and
information sharing. There was also an over-reliance on informal arrangements with
the liaison team and delay in referring the case to the Community Mental Health
Team. The Ombudsman was also critical that there had been no appropriate
independent review immediately following the death. An investigation carried out
following Internal Review, although robust in its findings failed to convince the family
because it was carried out by employees of the Health Board. There were also
complaint handling failures and the Ombudsman recommended a payment of £250.
The UHB made significant changes and was required to produce evidence to show
that matters had been put right.
Case reference 201000808
July 2011 – Clinical treatment in hospital – Betsi Cadwaladr University Health
Board
A was admitted to Ysbyty Gwynedd on 19 January 2009 due to her knee giving way
following an accidental twist. A also had a history of injury to both knees. Following a
number of clinical investigations, the first consultant decided a conservative
approach with physiotherapy was the appropriate treatment option and A’s discharge
was planned for around 23 January. A considered that her condition had not been
properly diagnosed prior to this planned discharge. A also complained that she
suffered with increasing pain but was encouraged to continue with physiotherapy. A
requested a second medical opinion which she believed she had to fight for and was
made to feel a nuisance. A received a second opinion on 24 January from the
second consultant, who later carried out an Arthroscopy procedure. A considered
that this had been the treatment which was required from the outset. A also
complained that there were shortcomings in the complaint handling process in that
her complaint had not been responded to fully or accurately by the Health Board.
The Ombudsman did not uphold the complaints that there had been a delay in A
receiving the correct procedure or that her planned discharge was inappropriate. A’s
complaint about the continuation of physiotherapy was also not upheld. The
Ombudsman did uphold A’s complaint that there were shortcomings in the process
of her obtaining a second opinion and upheld her complaint about the failings in the
Health Board’s management of her complaint specifically in terms of the fullness of
its responses. Due to shortcomings in the recording of events at the time of the
request for a second opinion the Ombudsman could not make a judgement on the
accuracy of the Health Board’s responses. The Health Board was recommended to
apologise to A & confirm it has in place both an effective complaint handling
procedure and a clear procedure for dealing with patient requests for a second
opinion.
Case reference 201001354
June 2011 – Clinical treatment in hospital – Betsi Cadwaladr University Health
Board (formerly North Wales NHS Trust)
Ms F complained about the care provided for her late father, Mr D, by the Trust, when
he was in hospital. She expressed concern about its management of his falls, his
nutritional care, his fluid intake, his transfer to the Rehabilitation Unit and his pain
relief. She suggested that its prescription of Haloperidol and Movicol, for him, was
inappropriate. She complained that it did not try to replace Mr D’s hearing aids and
glasses.
The Ombudsman fully upheld those elements of Ms F’s complaint which concerned
Mr D’s falls, his nutritional care and his Haloperidol prescription. He partly upheld the
transfer aspect of it. He recommended that the Health Board should apologise to Ms
F and Mrs D for the failings identified. He asked it to provide training on the Trust’s
Incident and Hazard Reporting Policy for staff members. He recommended that it
should review the processes used by members of the Multi-Disciplinary Team for
exchanging information. He asked it to remind staff members of the need for
accurate record keeping. He recommended that it should review its Guidelines for
the Inpatient Management of Delirious Elderly Patients and its delirium management
training with reference to guidance issued by the National Institute for Clinical
Excellence. He asked it to consider whether it is necessary for it to have a policy on
the use of laxatives. He recommended that it should devise and implement a laxative
policy if it concludes that it is necessary for it to have one.
The Health Board agreed to comply with all of the recommendations. The
Ombudsman did not uphold those parts of Ms F’s complaint which concerned Mr D’s
Movicol prescription, his fluid intake and his pain relief. He did not make a finding in
relation to the hearing aids and glasses aspect of Ms F’s complaint.
Case reference 201002402
June 2011 – Clinical treatment in hospital – Betsi Cadwaladr University Health
Board (UHB)
Following an accidental twist in which her knee gave way, ‘A’ (who has a history of
injury to both knees) was admitted to Ysbyty Gwynedd on 19 January 2009.
Following a number of clinical investigations, the First Consultant decided a
conservative approach with physiotherapy was the appropriate treatment option and
A’s discharge was planned for around 23 January. ‘A’ considered that her condition
had not been properly diagnosed prior to this planned discharge. She also
complained that she suffered with increasing pain but was encouraged to continue
with physiotherapy. She requested a second medical opinion which she believed
she had to fight for, and was made to feel a nuisance. ‘A’ received a second opinion
on 24 January from the Second Consultant who later carried out an Arthroscopy
procedure. ‘A’ considered that this had been the treatment which was required from
the outset. ‘A’ also complained that there were shortcomings in the complaint
handling process in that her complaint had not been responded to fully or accurately
by the Health Board.
The Ombudsman did not uphold the complaints that there had been a delay in A
receiving the correct procedure or that her planned discharge was inappropriate. A’s
complaint about the continuation of physiotherapy was also not upheld. The
Ombudsman did uphold A’s complaint that there were shortcomings in the process
of her obtaining a second opinion and upheld her complaint about the failings in the
Health Board’s management of her complaint, specifically in terms of the fullness of
its responses. Due to shortcomings in the recording of events at the time of the
request for a second opinion, the Ombudsman could not make a judgement on the
accuracy of the Health Board’s responses. The Health Board was recommended to
apologise to A, and confirm it has both an effective complaint handling procedure
and a clear procedure for dealing with patient requests for a second opinion in place.
Case reference 201001354
Other reports - Not Upheld
March 2012 – Clinical treatment in hospital – Betsi Cadwaladr University Health
Board
Miss R complained about the care and treatment provided to her father, Mr R, during
an emergency call out to his home and subsequent admission by ambulance to the
A&E Department at Glan Clywd Hospital. Mr R had awoken with central chest pain
when an emergency call was made by his daughter. On arrival, the paramedic
identified that Mr R’s chest pain was cardiac related and quickly arranged his
transfer to hospital.
Miss R complained about the following:








That the paramedic who attended her father panicked and failed to provide
him with appropriate pain relief medication.
That her father was not assisted to lie flat with his feet elevated.
That the family were not allowed to accompany Mr R during his transfer by
ambulance to hospital.
That thrombolysis treatment (used in the treatment of blood clots) was not
administered at an earlier stage which impacted on her father’s chances of
survival.
That the family were not allowed to see Mr R when he was alive in the
resuscitation room.
That the location of her father’s bruising was incorrectly identified.
The tone and attitude of a member of the nursing staff towards the family
during her father’s hospital admission.
That the Welsh Ambulance Services NHS Trust (“the Trust”) delayed in
providing Miss R and the family with a response to their concerns regarding
the paramedic’s actions during the emergency call out.
The Ombudsman found that although there had been an excessive delay by the
Trust in providing Miss R with a response to her concerns, overall, the incident was
appropriately handled by the paramedic. The Ombudsman concluded that the
paramedic had acted in accordance with relevant guidelines and in the best interests
of Mr R during the emergency call out to his home and transfer by ambulance to
hospital. The Ombudsman found that due to Mr R’s condition pain relief medication
and thrombolysis treatment could not be administered by the paramedic.
The Ombudsman found that the care and treatment provided to Mr R during his A&E
admission was appropriate and timely and there was no further action that the
hospital staff could have taken to avoid Mr R’s sad death. Ultimately, the
Ombudsman concluded that a thorough assessment of Mr R was required before
further treatment could be administered and that Mr R’s death occurred due to a
sudden complication in his condition. Such a complication is not uncommon in a
patient who seems to be experiencing a heart attack and has other complications
including low blood pressure, as in this case.
Case reference 201100215
March 2012 – Clinical treatment in Hospital – Betsi Cadwaladr University
Health Board
Mr Y complains about his late wife’s treatment (surgery and hormone therapy) for
breast cancer in September 2005. Unfortunately Mrs Y was diagnosed with a
primary oesophageal cancer in January 2006, there were signs of disease in the liver
and sadly she died in November 2006. Following local publicity about mistakes in
pathology reports Mr Y said that the breast cancer treatment was not sufficient
because of a flaw in the pathology report. He maintains that because Mrs Y did not
receive radiotherapy or chemotherapy following the removal of her breast that the
cancer spread to the oesophagus.
The Ombudsman found, after taking independent clinical advice, that Mrs Y’s breast
cancer treatment was the most appropriate treatment based on the scan results at
the time and the absence of tumour in the lymph nodes. There would have been no
advantage to her receiving chemotherapy for the breast cancer which tests had
showed was of a type stimulated to grow by hormones. Further tests carried out by
the Health Board during the investigation showed that the oesophageal tumour was
not hormone receptive i.e. was another primary tumour and not secondary to the
breast cancer. Contrary to Mr Y’s views he also found that the extent of
chemotherapy treatment for the second cancer was appropriate and had not been
stopped prematurely. The Ombudsman upheld the part of Mr Y’s complaint relating
to missing records for an unreasonable period, but found that this did not affect his
ability to progress the complaint.
Case reference 201100553
March 2012 – Clinical treatment in hospital – Betsi Cadwaladr University Health
Board
Ms G complained that Betsi Cadwaladr University Health Board (‘UHB’) failed to
carry out all of the necessary diagnostic tests which resulted in her kidney condition
not being properly and fully investigated.
The Ombudsman did not uphold the complaint. He took the view that all necessary
and appropriate tests were carried out by the UHB, in particular there was no
indication that an MRI scan should have been carried out.
The Ombudsman was also satisfied that Ms G’s treating clinicians had appropriate
discussions with her concerning a renal biopsy.
The Ombudsman took the view that Ms G’s test results were appropriately recorded
and properly interpreted. He was satisfied that the overall standard of care received
by Ms G was reasonable.
Case reference 201100103
February 2012 – Clinical treatment in hospital – Betsi Cadwaladr University
Health Board
Mr X complained about the care given to his wife after her diagnosis with a serious
blood disorder in early 2008. The clinicians Mrs X saw were unsure of the precise
diagnosis, but described her illness variously as myeloproliferative disease,
myelodysplastic disorder and myelofibrosis. Mr X complained about the Consultant
Haematologist’s attitude and what he believed was his inadequate understanding of
Mrs X’s condition; he also complained about aspects of her care during the course of
her illness. Despite Mrs X seeing a number of specialists at various hospitals in
England, she sadly died on 3 April 2010.
The Ombudsman found that Mrs X’s condition had features commonly associated
with each of the syndromes, making categorising her illness difficult. Nevertheless,
the treatment which Mrs X received was appropriate to all the sub-categories. Other
than supportive care in the form of transfusions, any therapies for Mrs X’s condition
were either experimental or usually ineffective, and Mrs X’s treatment was
reasonable. In the absence of any independent evidence of what was said, the
Ombudsman was unable to determine whether the exchanges between the
Consultant and Mr X went further than a frank exchange of opinions. He did not
uphold the complaint.
Case reference 201100656
August 2011 – Clinical treatment in hospital – Betsi Cadwaladr University
Health Board
Mrs P complained that she was afforded sub-standard care in respect of a postoperative bout of diarrhoea, that a firm diagnosis was delayed and that she was
transferred to another hospital in a dehydrated condition. Mrs P complained that
clinicians at the hospital to which she was transferred had to rehydrate her due to the
poor care she had received up to that point and that clinicians at that hospital were
subsequently able to provide a clear diagnosis for her condition.
The Ombudsman found that although there was a slight delay in completing
diagnostic tests, the overall care Mrs P received was of a reasonable standard. The
Ombudsman, having taken appropriate clinical advice, found that although infection
as a cause of her symptoms could have been ruled out at a slightly earlier stage, the
Trust’s approach had been appropriate and had not adversely affected the ultimate
outcome of her illness. He also concluded that there was no evidence that Mrs P
was dehydrated upon transfer.
Case reference 201002694
July 2011 – Clinical treatment in hospital – Betsi Cadwaladr University Health
Board
Mrs A’s mother was referred for investigations to the Gynaecological Clinic at Ysbyty
Gwynedd Hospital in April 2008 following a rise in her serum CA1251 which was
being measured annually through her participation in an ovarian cancer screening
trial. The hospital arranged for repeat blood tests and upper abdominal scans. The
scans were found to be normal and no cause was found for the elevated serum
CA125. Mrs A’s mother was discharged from the Gynaecology Clinic in July 2008
but remained on the trial where she was returned to routine screening. In March
2009, Mrs A’s mother was diagnosed with metastatic ovarian cancer and sadly
passed away a few weeks later following complications of her chemotherapy.
Mrs A complained to the Health Board shortly after her mother had died about the
delay in the diagnosis of her ovarian cancer. She said that the Hospital Consultant
did not arrange the proper follow up in view of the implications of her mother’s
persistently elevated serum CA125 and that her death could have been avoided.
The Ombudsman did not uphold the complaint. He found that it was not an
unreasonable decision, at that time, for the Hospital Consultant to discharge Mrs A’s
mother from his clinic back to the trial with continued follow up. Sadly it was also the
case that an earlier diagnosis and treatment of her cancer, was unlikely to have
made a difference to the type of treatment Mrs A’s mother received, or to the
outcome of that treatment. In reaching his view, the Ombudsman took into account
the advice provided by an independent Clinical Adviser.
Case reference 201000243
May 2011 – Clinical treatment in hospital – Conwy and Denbighshire NHS Trust
(now Betsi Cadwaladr University Health Board) & a GP Practice in Betsi
Cadwaladr UHB area
Mrs C made a complaint about the standard of care provided to her late father, Mr D,
by both his GP Surgery and the Health Board. She complained that Mr D was
admitted by the GPs to the local Community Hospital which was inappropriate for his
condition. He was then transferred to the District Hospital and Mrs C raised concerns
that insufficient urgent investigations were done into Mr D’s condition. She also
complained about his pain management and nutrition. Finally, she was concerned
that the family were not kept informed of the severity of his illness. Eventually the
diagnosis of mesenteric ischemia was reached but sadly Mr D died very soon after.
Having obtained independent clinical advice, the Ombudsman concluded that it was
reasonable for the GPs to admit Mr D to the Community Hospital and the care
provided to him there was appropriate. He therefore did not uphold the complaint
against the GP Surgery.
In relation to the complaint against the Health Board about Mr D’s hospital care, the
Ombudsman found that appropriate and timely investigations into Mr D’s condition
were carried out. It was acknowledged that mesenteric ischemia is a difficult
condition to diagnose. He also concluded that the communication with the family was
acceptable. Whilst the pain relief given to Mr D was not unreasonable, the
Ombudsman suggested that involvement of a pain specialist in Mr D’s care would
have enabled more effective management of his fluctuating pain levels. The
Ombudsman also expressed concern about Mr D’s nutritional intake as it was noted
that he had lost a considerable amount of weight and was seriously underweight.
The Ombudsman’s clinical adviser’s view was that additional feeding, such as
parenteral feeding (whilst ultimately it may have been unsuitable for Mr D) should
have been considered. The Ombudsman therefore upheld the complaint against the
Health Board to a limited extent.
Case reference 201000579 & 201000589