PSOW Individual Decisions

Mrs A complained to the Ombudsman about the care given to her late father, Mr B, by Cardiff and Vale University Health Board. As a result of a previous stroke, Mr B was being treated with an anticoagulant to prevent the formation of blood clots which could lead to a stroke. Because Mr B needed to have surgery to address issues of rectal bleeding, his anticoagulant was suspended. On the day following his surgery, whilst recovering on the ward, he was noted to be confused and disorientated. Nursing staff called a doctor who saw Mr B at 13:00 and concluded that while Mr B had no evidence of any neurological problems he should not be sent home, and arranged a chest X-ray and other tests. The same doctor reviewed Mr B nearly 5 hours later, and arranged a CT scan of his head as Mr B appeared confused, which at approximately 19:00 indicated that Mr B had experienced a stroke. A review by another doctor at approximately 21:00 concluded that it was too late for clot-busting therapy although anti-platelet therapy (to stop cells in the blood from sticking together to form further clots) was arranged. Mr B’s condition deteriorated further and sadly he died in hospital. Mrs A also complained about the manner in which the Health Board dealt with her subsequent complaint. The Ombudsman found that the diagnosis of Mr B’s stroke was unreasonably delayed. He was already at a heightened risk of having a stroke as a result of the suspension of his medication, (which could have reduced that risk), there had been a sudden and significant change in his condition and early stroke diagnosis is crucial for treatment purposes. The Ombudsman also found that the Health Board took too long to consider Mr B’s treatment options and to start his stroke-related treatment. The Ombudsman also found the Health Board’s failure to identify its shortcomings when responding to the family’s concerns demonstrated that it did not investigate their concerns properly, leading to additional distress. The Ombudsm

Miss A complained about several issues relating to the care provided to her late mother before her death, including whether she was adequately monitored, whether her observations/presentations were normal and whether her care was escalated appropriately. She also complained that her mother’s medical records relating to the admission were missing. In the absence of the relevant medical records the Ombudsman was unable to consider the adequacy of the clinical care provided. This represented a significant injustice to Miss A and her family. The Ombudsman contacted the Health Board and in resolution of Miss A’s complaint it agreed that within 20 working days it would provide Miss A with a meanful apology for the loss of records, make a redress payment of £1,500 for the lost opportunity to have her complaint considered, to continue searching for the records and tore-iterate the offer of a meeting with the family.

Mr A complained about treatment provided by Cardiff and Vale University Health Board’s Dental Hospital. He said that the removal of 3 teeth had resulted in difficulty eating and his speech being affected. The Ombudsman found that the Health Board had failed to contact Mr A to agree with him the parameters of his complaint before investigating and responding, as it informed Mr A that it would do. The Health Board explained that this was due to confusion with Mr A’s email address but offered to meet with Mr A to discuss his experiences fully and to see if it was able to offer any further assistance to him, within 20 working days. The Ombudsman considered this to be an acceptable resolution to Mr A’s complaint and did not investigate.

Mr A complained that, following a Child Protection Medical Examination to investigate unexplained bruising to his 8 week old grandson, X, staff at the Health Board identified further potential injuries, most significantly one they identified as a skull fracture. This led to a multi-agency decision to remove X from his parents’ care and place him with Mr A. When the case went to court a specialist found that it was more likely that the skull fracture was a naturally occurring suture and X was returned to his parents. Mr A complained about the actions of the Health Board, about comments that were made by Health Board staff relating to whether he was suitable to look after X, and the Health Board’s complaint response. The investigation found that the radiologists involved should reasonably have been expected to know about possible alternative diagnoses and should have identified these in their reports. This was a failing and these elements of the complaint were upheld, with the caveat that it was not possible to establish the extent to which this would have influenced the paediatricians’ safeguarding report. However, as the ‘skull fracture’ was never established to be conclusively misdiagnosed and the decision to remove X was not made by the Health Board, the investigation found that the Health Board would not have been expected to express regret or culpability in its complaint response to Mr A. It also found that, given the information available to the paediatricians, the finding that the ‘skull fracture’ was most likely a non-accidental injury was a reasonable conclusion, and that X-rays were a required part of the safeguarding process. These elements of the complaint were therefore not upheld. Finally, the investigation found that while it would not be appropriate to restrict what comments staff could make if they had child protection concerns, the way this was handled (both at the time and in response to Mr A’s subsequent formal complaint) could have been improved,

Ms B complained on behalf of her late mother, Mrs C, about the treatment and care provided at the University Hospital of Wales (“the Hospital”) when she developed difficulty with her breathing and was admitted to the Emergency Department (“ED”). In particular, Ms B said that the Health Board failed to initiate early treatment with non-invasive ventilation (“NIV” – additional breathing support through a tight-fitting mask) and to take any action to remedy identified failings in Mrs C’s care when responding to her complaint. The investigation found that there were failings during the initial triage and medical assessment which meant that Mrs C’s care was not appropriately prioritised and escalated to a senior doctor for review. Mrs C was very unwell on admission to the Hospital and early treatment with NIV provided the only possibility of reversing her respiratory failure. Sadly, Mrs C was too unwell to benefit from NIV treatment by the time a senior medical review took place and she died later that day. Because of these failings, Ms B has been left with some uncertainty about Mrs C’s outcome which causes her an injustice. Ms B also raised concerns about the impact of sedation and her medical history on the later decision to withhold NIV treatment. These complaints were not upheld. The Ombudsman recommended that the Health Board should apologise to Ms B and make a redress payment of £1000 in recognition of the failings in Mrs C’s care and the failure to learn and improve from the complaint. The findings should also be shared with the nursing staff in the ED to emphasise the importance of using standardised early warning systems to ensure that the most time-critical patients are prioritised appropriately for medical review.

Miss A complained on behalf of her late sister, Miss B,about delays by the Health Board (“the Health Board”) when diagnosing herendometrial cancer (cancer of the womb lining). The Ombudsman found that earlier investigations for suspected cancer following an urgent referral in2017 were overly delayed and had also been inappropriate. Although excessive or abnormal thickening of the womb lining carries a risk of progression to cancer, the Health Board failed to undertake imaging of Miss B’s pelvis without her intrauterine system (a plastic device inserted into the womb) in place for accurate measurements of the womb lining to be taken. Whilst Miss B’s presenting symptoms indicated that investigations of her womb were called for, inappropriate investigations of her cervix were also pursued. It was unlikely that Miss B’s cancer was present in 2017, however it was possible that earlier pre-cancerous changes and opportunities for intervention might have been identified, potentially altering the course of Miss B’s disease. There was also a delay of 3 months in 2019 before Miss B’s cancer was diagnosed. After Miss B’s second emergency hospital admission in March 2019, the Gynaecology Medical Team ought to have suspected cancer and arranged further investigations because her symptoms were not responding to treatment. Instead, Miss B was referred back to her GP for further management. It was unlikely that an earlier diagnosis would have affected the course of Miss B’s disease as it was aggressive and resistant to chemotherapy, however there were multiple medical appointments, futile treatments and ongoing distressing symptoms that might have been avoided. The complaint was upheld. The Ombudsman recommended that the Health Board should apologise to Miss A for the failings in her sister’s care and review the appropriateness of the urgent cancer pathway in 2017 and the failure to consider cancer as a cause of Miss B’s symptoms in March 2019. It should also present the findings of

Ms A complained about the dentalcare and treatment provided by the Dental Practice for her son’s injured front tooth. Ms A said that the Dentist had given contradictory and incorrect advice about her son’s treatment plan and the need for specialist referral. Ms A was also concerned that Dentist who had provided her son’s care had written the response to her complaint. She said that the response was not objective and had failed to answer the complaint that she made. The Dental Practice also wanted to charge her for providing a copy of her son’s dental records. In response to the investigation, the Dental Practice agreed to review the requirements around providing written treatment plans for NHS patients to prevent misunderstandings about care in the future. The Dental Practice also agreed to provide the following to Ms A: a) a fulsome apology for the for the shortcomings in communication and the poor response to her complaint b) a more comprehensive and objective response to her complaint c) a copy of her son’s dental records free of charge As Ms A’s son had already been referred by the Dental Practice for specialist care and his injured tooth had been restored, the Ombudsman considered that it was proportionate to discontinue the investigation based on the actions agreed.

Mrs Y complained to the Ombudsman (via her Community Health Council (CHC) advocate) about Cardiff and Vale University Health Board’s response to her concerns surrounding her husband’s (Mr Y) care prior to his death on 21 July 2021. She also had concerns regarding communication around his deteriorating condition due to symptoms of heart failure and issues with how a meeting was conducted, with key personnel not being present. The Ombudsman sought advice from a professional clinical adviser and found that the care given to Mr Y prior to his death was reasonable. The Ombudsman also found that nothing further could be achieved in respect of communication errors by the Health Board. It had apologised for these and this was deemed sufficient. However, the Ombudsman was concerned that no representative from the hospice (to which Mr Y had been transferred before his death) was at Mrs Y’s meeting with the Health Board. This did not enable the Health Board to satisfactorily resolve her complaint in full. The Ombudsman sought and gained the Health Board’s agreement to liaise with the hospice and the CHC to arrange a follow-up meeting with Mrs Y, with a hospice representative present, within 20 working days.

Mr C complained that Cardiff and Vale University Health Board had failed to adequately address his concerns about the care and treatment provided to his late father. The Ombudsman found that whilst the Health Board had issued a complaint response it had delayed making further contact with Mr C about his outstanding concerns. She said this caused frustration to Mr C. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr C and issue a further complaint response within 6 weeks.

Ms X complained to Cardiff and Vale University Health Board about the care and treatment provided to her late mother, Mrs X. Ms X said that the response to her complaint, provided by the Health Board, contained inconsistencies, and failed to properly address her complaint. The Ombudsman found that the Health Board’s complaint response did contain inconsistencies and contradictions. She also found that it did not properly address Ms X’s complaint. Additionally, the Ombudsman was concerned that the Health Board’s clinical diagnosis of Mrs X’s condition differed from the subsequent post mortem findings and that Ms X had not been provided with an opportunity to discuss the findings with the Health Board. The Ombudsman contacted the Health Board and in resolution of Ms X’s complaint, it agreed to, within 20 working days, arrange a meeting with Ms X to address her unresolved complaint issues and to discuss the results of her late mother’s post mortem examination.

Mrs X complained about the fact that Cardiff and Vale University Health Board used a right-sided knee replacement component being used when she underwent a left-sided total knee replacement. She said that the Health Board failed to explain the implications of the wrong sided prosthesis being used. The Ombudsman found that whilst the Health Board had admitted to a failure in its procedures, it had not explained to Mrs X about any possible implications for her, nor what aftercare it intended to provide intended to monitor Mrs X’s clinical condition. This situation resulted in Mrs X experiencing stress and worry about the uncertainty. The Ombudsman contacted the Health Board and in resolution of Mrs X’s complaint it agreed to, within 20 working days, arrange a meeting with Mrs X to assist her with understanding the implications of having the wrong sided knee prosthesis fitted together with an explanation about the type of aftercare she would receive to monitor the situation.

Mrs B complained that following the birth of her son, C, the Health Board missed opportunities to identify his urachal remnant (“UR” – a condition where the channel which forms between the baby’s bladder and the umbilical cord during pregnancy does not close as it should prior to birth). The investigation found that the care provided to C after his birth was appropriate and that there were no failures by clinical staff to take actions that would have led to an earlier diagnosis of the UR. Accordingly, the Ombudsman did not uphold the complaint.

Mr D complained that Cwm Taf Morgannwg University Health Board (“the First Health Board”) failed to provide care and support to his late daughter, Miss E, when her mental health deteriorated during 2020. Mr D said the First Health Board failed to transfer her section 117 aftercare (free help and support following a hospital stay under the Mental Health Act delivered by the First Health Board and the local authority (“the Council”)) when she moved into a different area covered by Cardiff and Vale University Health Board (“the Second Health Board”), and did not carry out Miss E’s wishes in her care plan to continue providing care despite the move. The Ombudsman’s investigation found that whilst Miss E had been discharged from the First Health Board’s Community Mental Health Team (“CMHT” – also made up of staff from the Council) in 2016, she was not informed of her right to self-refer back to the CMHT (within 3 years) if her mental health deteriorated, contrary to relevant guidance. This was a service failure and caused an injustice to Miss E as she did seek help from the First Health Board’s CMHT within the specified timeframe. The Ombudsman also concluded that the transfer of Miss E’s section 117 aftercare (which ultimately did not happen) was disjointed and uncoordinated. Both the First and Second Health Boards seemed either confused or reluctant to transfer, or take on the transfer, of Miss E’s aftercare. This was a service failure that caused Miss E the injustice of being unable to access timely mental health care which would have been likely to cause her anxiety and potential distress. Furthermore, when Miss E’s mental health deteriorated during 2020, and she sought assistance from the First Health Board, the First Health Board missed an opportunity to evaluate her and formally transfer her section 117 aftercare to the Second Health Board. When Miss E agreed to a mental health referral to the Second Health Board, but then withdrew it, it was the Ombudsman’s view

Miss X complained about the care and treatment her late father, Mr Y, received at University Hospital of Wales (“the Hospital”) in March 2020. He went to the Emergency Department (“the ED”) but was sent home. Two days later, he was admitted to the Hospital but sadly died a few days later having had emergency surgery. The Ombudsman investigated whether Cardiff and Vale University Health Board: • inappropriately discharged Mr Y from the ED • failed to diagnose a bowel obstruction/strangulated hernia sooner and whether this impacted on his death • failed to follow the correct do not attempt cardiopulmonary resuscitation process (“DNACPR” – where the heart or breathing stop, and the healthcare team decide not to try to re-start them). The Ombudsman found that Mr Y was inappropriately discharged from the ED as a result of several shortcomings in the approach to his care. These included a failure to adequately assess his clinical history and new symptoms. The Health Board did not take enough information about Mr Y’s bladder symptoms, constipation and new large groin lump. These symptoms pointed to an obstructed hernia which needed treatment, but Mr Y was discharged without adequate assessment. Further assessment and admission at this time might have changed the outcome for him. This complaint was upheld. Mr Y was admitted to the Hospital 2 days later. The Ombudsman found that his symptoms at this time were typical of a strangulated hernia with bowel obstruction, and this should have been recognised. Failure to do so led to a delay in Mr Y undergoing surgery which meant that his condition got worse. There were missed opportunities to repeat an abdominal X-ray and to carry out a CT scan sooner. The CT scan led to the diagnosis of an obstruction from the hernia. This diagnosis resulted in emergency surgery. Had Mr Y been appropriately and urgently investigated and diagnosed on the day he was admitted, and undergone surgery sooner, his chances of survival would have been impr

Mr X was 78 years old, suffered with type 2 diabetes (on insulin), idiopathic pulmonary arterial hypertension, heart failure, previous lung and colon cancers, atrial fibrillation, and osteoarthritis. Mrs X complained about the treatment her late husband, Mr X, received from the family GP on 17 February 2021 and from the OOHGP on 21 February. On 9 February 2021 Mr X was administered the COVID-19 vaccination (“the vaccination”). Mrs X said that Mr X’s vaccination made him unwell and that both GPS ignored her concern about Mr X’s condition being because of the vaccination. The Ombudsman found that concerns about the vaccination were not raised at the consultations. She also found that there was no indication that Mr X’s presentations were linked to the vaccination and that even had a link been suspected, it would not have influenced his management. The Ombudsman found that both consultations and treatments were to a reasonable standard. The complaint was not upheld.

Mrs X complained that the Health Board had not provided her with a response to the complaint she submitted to it 10months ago. The Ombudsman decided that there had been a delay in the Health Board’s complaint response, which led Mrs X to contact the Ombudsman. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its complaint response and apologise for the delay. It also agreed to pay Mrs X redress of £250 in recognition of the time and trouble she had expended.

Ms A complained about the treatment of her late sister, Mrs B, who contracted Covid-19 after being admitted to a hospital within the Health Board for an unrelated condition and sadly died. Ms A had received an initial complaint response under the Putting Things Right (“PTR”) process, but posed further questions to the Health Board after reading it. The Ombudsman contacted the Health Board and found that it was preparing a further PTR response to Ms A’s questions. The Health Board confirmed that its Covid-19 scrutiny panel had also separately considered the circumstances in which Mrs B contracted Covid-19, as per the National Nosocomial COVID-19 Programme. The Health Board agreed to provide the results of the Covid-19 scrutiny of Mrs B’s case, and a further PTR response addressing Ms A’s further questions, to Ms A within the next month.

Ms A complained about the treatment of her late sister, Mrs B, who contracted Covid-19 after being admitted to a hospital within the Health Board for an unrelated condition and sadly died. Ms A had received an initial complaint response under the Putting Things Right (“PTR”) process, but posed further questions to the Health Board after reading it. The Ombudsman contacted the Health Board and found that it was preparing a further PTR response to Ms A’s questions. The Health Board confirmed that its Covid-19 scruitiny panel had also separately considered the circumstances in which Mrs B contracted Covid-19, as per the National Nosocomial COVID-19 Programme. The Health Board agreed to provide the results of the Covid-19 scrutiny of Mrs B’s case, and a further PTR response addressing Ms A’s further questions, to Ms A within the next month.

Mr X complained about his experience as a transgender man accessing the Health Board’s services.  He raised concerns about a specific visit to the A&E Department and more general concerns about how the Health Board ensured that its services were inclusive for LGBTQ patients. Mr X felt that a meeting to discuss his experience with the Health Board would be useful to address his concerns.  The Health Board agreed to, within 4 weeks of the date of this decision, contact Mr X and arrange a meeting with him to discuss: the specific issues he raised about his care wider issues about the service provided to LGBTQ patients highlighted by his experience. The Health Board said that a member of the clinical team and its Equalities Officer would be present at the meeting.

Ms D complained about the decision of a GP Practice in the area of Cardiff and Vale University Health Board to remove her name from its patient list. She said that the Practice had not taken that decision properly because it made it before discussing its concerns with her, prior to giving her a warning and without taking into account all the relevant facts. The Ombudsman found that the Practice did not take its decision to remove Ms D’s name from its patient list properly. She made that finding, in relation to the decision-making process, for four reasons. Firstly, she was of the view that the Practice did not have full knowledge of the facts. Secondly, she was not satisfied that it considered giving Ms D a warning in accordance with relevant guidance. Thirdly, she was of the view that it did not complete a significant event analysis (a way of formally analysing an incident for learning purposes), as required by its “Violent and Aggressive Patient Policy” (“the Policy”). Finally, she noted that it was unable, despite relevant legislation and guidance, to provide any documentary or video evidence of the meeting in which it made this decision. She considered that those failings had caused Ms D a significant injustice in the form of uncertainty and distress. She upheld Ms D’s complaint. The Ombudsman recommended that the Practice should apologise to Ms D for mistakes related to its decision to remove her name from its patient list and for its failure to demonstrate that it took that decision properly. She asked it to inform the NHS Wales Shared Services Partnership (this body carries out GP registration duties on behalf of the Health Board) that it had not given Ms D a warning, as stated when it asked the Partnership to remove Ms D’s name from its patient list. She recommended that it should also ask the Partnership to update its records accordingly. She asked it to revise the Policy in light of the failings identified. The Practice indicated that it would implement th

Ms X complained that there was a delay in the Health Board responding to her complaint about the care and treatment received by her son in respect of his benign brain tumour. The Ombudsman contacted the Health Board, and it agreed to provide a response to Ms X’s complaint by 27 October 2022. It also agreed to apologise to Ms X for the delay its response. The Ombudsman considered this to be a sufficient resolution as an alternative to investigating the complaint.

Mr L complained that he was unhappy with his late father’s fall investigation undertaken by the Health Board. He further complained that the Health Board had failed his father who was in recovery at the time of his fall. The Ombudsman was concerned that Mr L had not yet received a full response from the Health Board under the ‘Putting Things Right ’regulations and therefore contacted the Health Board. The Health Board agreed that it would issue a full response to Mr L within 14 working days of the Ombudsman’s decision letter.). The Ombudsman accepted this as a resolution to Mr L’s complaint.

Mr X complained that the Health Board caused delay when it processed a referral from his GP to the All Wales Therapeutics and Toxicology Centre (“AWTTC”). He also complained there was a delay in providing him with the results of his Beta II Transferrin assay. The investigation found that the appointment arranged by the Health Board with the AWTTC fell within the 30-week waiting period it advised. The investigation further found: 1) that the Beta II Transferrin assay test was not arranged by the Health Board; 2) that the laboratory that provided the results of Mr X’s Beta II Transferrin assay did not fall under the responsibility of the Health Board; and 3) despite this, the Health Board chased the results and apologised to Mr X. The Ombudsman did not uphold the complaints. As no failings were identified, the Ombudsman did not make any recommendations regarding this complaint.

Mrs A complained about an out of hours GP (“OOHGP”) consultation that took place on 29 February 2020 at the residential placement (“the Placement”) where her son, B, who has a learning disability, autism, epilepsy and attention deficit hyperactivity disorder lived. In particular, she complained about: • The OOHGP’s conclusion that her son’s pain was not likely to be appendicitis. • Reasonable adjustments by the OOHGP and the Out of Hours Service especially in relation to communication and pain management. • Complaint handling. The following day her son was admitted to hospital and diagnosed and treated for appendicitis. The Ombudsman’s investigation found, after careful consideration of the evidence, that the OOHGP’s documented conclusion that B had a diarrhoeal illness was a plausible diagnosis based on B’s clinical presentation at the time and that the OOHGP had carried out an adequate assessment of B. The Ombudsman, regarding the disputed evidence about what was discussed by way of safety netting/worsening advice, found that even if the OOHGP did not provide the safety netting advice that he recorded that he had, this did not affect the subsequent course of events, as the Placement had acted correctly and sought appropriate medical assistance the following day. The Ombudsman, whilst not wishing to minimise the significant distress these events must have caused to B and his parents, nevertheless concluded that in terms of the consultation the OOHGP’s actions were not unreasonable and would not amount to service failings based on the Ombudsman’s clinical standards. The Ombudsman did not uphold this part of Mrs A’s complaint. On the issue of reasonable adjustments, the Ombudsman, while acknowledging Mrs A’s point of view and her concerns that she was not listened to, on balance, after taking the evidence as a whole, concluded that the adjustments the OOHGP made in terms of discussing B with his carers and Mr and Mrs A were sufficient. She did not uphold this part of

Mrs X complained about the Health Board’s failure to undertake an investigation into the concerns raised about the care and treatment her late husband, Mr X received from his GP Practice. The Ombudsman decided that the Health Board’s complaint response did not fully address the issues raised by Mrs X. The Ombudsman sought and gained the Health Board’s agreement to provide a response to the outstanding issues within 20 working days