PSOW Individual Decisions

Mrs A complained about the care and treatment provided to her late husband shortly before his sad death in December 2021. The Ombudsman decided that there was an opportunity for an independent external view to be sought by the Health Board in respect of the complaint. The Ombudsman sought and gained the Health Board’s agreement to contact Mrs A within 2 months in order to appoint an independent external expert to provide an authoritative view on whether the care and treatment provided to Mr A had been appropriate during the period of care in question.

Ms X complained that the Health Board had failed to respond to her complaint about the care provided to her during her pregnancy and labour, which she made to it in December 2021. In considering the complaint, the Ombudsman was concerned that the Health Board had not yet provided Ms X a written response. The Ombudsman therefore asked the Health Board to complete the following in settlement of Ms X’s complaint: By 2 September 2022 a) Apologise to Ms X for the considerable delay in responding to her complaint b) Provide Ms X with a written complaint response. 27 July 2022

Mr X complained that he was detained in Hospital, when he should not have been, for 5 weeks. Mr X also complained that, as a result of being detained incorrectly, he has encountered health issues. The Ombudsman was concerned that Mr X had yet to receive a formal response to his concerns from the Health Board and therefore contacted the Health Board. As a resolution to Mr X’s complaint, the Health Board agreed to issue Mr X with an apology letter for the delays in responding to his concerns, by 30 July 2022. The Health Board also agreed that it would issue Mr X with a formal response by 9 September 2022. The Ombudsman accepted this as a resolution to Mr X’s complaint.

Ms X complained that she was encountering concerns with her mental health team and that although she has put complaints forward to the Health Board, she is yet to receive a response. The Ombudsman was concerned that Ms X had yet to receive a response from the Health Board and therefore contacted the Health Board for further information. As an alternative to an investigation, the Health Board agreed that it would issue Ms X with an apology in responding to her concerns by 30 July 2022. The Health Board also confirmed that it would issue Ms X with a formal response to her concerns by 26 August 2022. The Ombudsman accepted this as a resolution to Ms X’s complaint.

Mr X complained that the Health Board had failed to prescribe him a newly approved medication called Fampridine, a drug used to improve walking ability in patients with multiple sclerosis. Mr X said this resulted in him paying for private prescriptions when he should have received the treatment from the NHS. The Ombudsman found that the Health Board had not adequately responded to Mr X’s concerns around the All Wales Medicine Strategy Group (AWMSG) guidance supported by Welsh Government that medicines should be available for prescription within 60 days. The Health Board agreed to an early resolution of Mr X’s complaint which included: Within 20 working days of the date of this letter, the Health Board will: 1. Write to Mr X to apologise for the inconvenience in needing to bring the matter to the Ombudsman before a resolution could be agreed 2. Reimburse Mr X for the cost of the medication he self-funded during the period March 2020 to July 2021, subject to Mr X being able to provide full documentation supporting the payments made during this time. Within 40 working days of the date of this letter, the Health Board will: 3. Conduct a review of all current Multiple Sclerosis patients to ensure there are no other patients who have been similarly self-funding this medication. It is noted Mr X has requested a refund from January 2020 but the 60 days allowed by AWMSG means it is reasonable to refund from March 2020.

Mrs X’s complaint related to the care and treatment that her late husband, Mr X, received during his admission to the University Hospital of Wales in November 2020. Specifically, Mrs X complained that a Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) form was inappropriately placed on her husband’s records against her wishes and without her permission. She also complained that the decision to stop active treatment, and move to end of life care, after only 3 days of her husband’s admission was inappropriate and premature, and that he was intentionally given morphine to overdose him and hasten his death. Mrs X said that the Health Board failed to give sufficient consideration to her views on these decisions. Finally, Mrs X also complained that her husband was not discharged from hospital to allow him the opportunity to die peacefully in his care home and that she was contacted by the Health Board’s Bereavement Team several months after his death. The Ombudsman concluded that the DNACPR decision was appropriately made and that the decision to change to end of life care on 23 November was a reasonable one as, sadly, Mr X’s condition had deteriorated despite receiving appropriate treatment for COVID-19pneumonitis. The Ombudsman also found that the medications, including morphine, that Mr X was subsequently prescribed were appropriate and that there had been an appropriate level of communication with Mrs X in relation to these decisions. In addition, the Ombudsman considered that it would not have been possible for Mr X to have been discharged back to his care home due to the speed of his deterioration and in the context of the COVID-19 pandemic. As a result, the Ombudsman did not uphold these complaints. However, the Ombudsman upheld Mrs X’s complaint relating to the Bereavement Team as the Health Board accepted that the bereavement support service set up during the pandemic should have contacted Mrs X far sooner than April 2021. The Health Board explained that s

Ms A complained about the care and treatment provided to her late partner when, in December 2020, he was admitted to the University Hospital of Wales with severe COVID-19. She also complained that she had not received a copy of the Mortality Review Report and that a meeting to discuss it had not been arranged. The Ombudsman did not consider it was reasonable to exercise discretion in considering the complaint out of time. However, decided to settle the other issues. She sought and obtained the Health Board’s agreement to provide the outstanding documentation and to arrange a meeting within 2 weeks of the issue of the decision.

Mrs X complained about the care and treatment provided to her daughter, Miss A, by the Health Board in relation to her eyesight and a possible stroke. Mrs X also said that the Health Board would not accept her complaint due to it being deemed as out of time. The Ombudsman found that whilst the eyesight element of Mrs X complaint was out of time, Mrs X only became aware of the possibility that Miss A may have suffered a stroke in August 2021, when she received a letter from a consultant. The Health Board agreed to complete the following in settlement of Mrs X’s complaint by 10 September 2022, as an alternative to the Ombudsman investigating it: a) Hold a virtual meeting with Mrs X and a paediatric consultant to further discuss the care Miss A received by the Health Board and the results of any investigations that were undertaken at that time.

Ms L complained that the Health Board failed to take appropriate safety measures in applying an alcoholic solution of chlorhexidine (a substance used to sterilise the skin) whilst cannulating her baby daughter, M (inserting a thin tube into the vein to administer medication or drain fluid) in preparation for surgery. Ms L also complained that staff failed to change the continence sheet despite M’s groin being sprayed with chlorhexidine on multiple occasions. The Ombudsman upheld the complaint. The Ombudsman found it was very likely that M sustained burns through extended contact with chlorhexidine solution that had pooled on the continence sheet, and that appropriate safety measures were not taken, nor was the continence sheet changed as it should have been. The Ombudsman noted that the risks of skin damage from the use of chlorhexidine solutions were already known, and that a similar incident involving a baby had occurred within the Health Board 3years earlier. The Ombudsman noted that the solution had been applied using an unmetered spray, and that the Health Board should have considered the use of “prepsticks”,single use applicators with a sponge tip, as a safer alternative. The Ombudsman considered that the Health Board had failed to learn from the previous incident and national guidance, and that had it made changes to its procedures, the likelihood of M suffering burns could have been reduced. The Ombudsman also found that the Health Board’s response lacked openness and did not acknowledge that pooling was known to be a risk with the use of chlorhexidine solutions, or that a similar incident had previously occurred. The Ombudsman recommended that within a month of the report, the Health Board apologise to Ms L and pay her a total of £1500 in recognition of the pain suffered by M, the distress, disruption and anxiety caused to her parents and the Health Board’s poor handling of her complaint. The Ombudsman further recommended that within 3 months of the report,

Mrs B complained that the Health Board had failed to properly consider her concerns about medication that was prescribed to her Aunt, Mrs C, during her admission to hospital in April 2020. Mrs C was prescribed morphine, despite being allergic to it, along with a sedative. Mrs B questioned whether this was appropriate given that the Medicines and Healthcare products Regulatory Agency (“the MHRA”) recommends extreme caution when prescribing those types of medication together. The Ombudsman found that the Health Board’s complaint response was inaccurate and contradictory. It stated that Mrs C’s morphine allergy had not been identified but there was evidence it had been noted by a Triage Nurse. It also said initially that Mrs C was not given morphine, but then subsequently confirmed that 2 doses of Oramorph (liquid morphine) were given with no ill-effect. There was also no response to the concern that the prescriptions might have been contrary to the MHRA guidelines. The Health Board agreed to write to Mrs B within 1 month to apologise for the poor complaint handling, offer £250 for her time and trouble pursuing the complaint and provide reassurance that lessons had been learned. It also agreed to specifically address the contradictions in the complaint response as well as the clinical implications and relevance of the MHRA prescribing guidelines and the 2 doses of Oramorph that were administered to Mrs C in the presence of a morphine allergy. 18 June 2022

Mrs A complained that during her admission to the Medical Assessment Unit (“MAU”) within the University Hospital of Wales between 11 and 12 February 2020, based on her reported and observed symptoms, the appropriate investigations were not undertaken (namely a spinal X-ray and a Vitamin D test) nor were appropriate examinations performed (namely an examination by the Trauma and Orthopaedic Team). Consequently, Mrs A said that she was misdiagnosed and as a result has suffered significant physical and psychological trauma. The investigation found that there had been a failure to arrange Vitamin D and Calcium tests. Whilst these were not clinically indicated in the acute setting of MAU, they formed part of the documented clinical plan. In addition, consideration should have been given to referring Mrs A for an outpatient CT or MRI scan given the osteoporosis risk factors and severe pain she experienced. It was not possible to determine whether the fractures would have been identified earlier if the tests and / or investigations had been performed. Nor was it possible to establish whether earlier identification would have limited the physical pain and psychological ramifications. However, the uncertainty alone represented an injustice to Mrs A. The Health Board agreed to apologise to Mrs A, provide minutes of a meeting held in April 2022 and to disseminate a circular to the on-call medical team reminding them of the importance of undertaking all aspects of a clinical plan and record if any aspect is repealed. It also agreed to ensure that its Frailty and Osteoporosis teaching sessions outlined the risk factors for fragility fractures and provided an emphasis on early identification and onward referral for management and treatment.

Mrs X complained that the Health Board had failed to respond to her complaint about being administered medication that she was allergic to. Mrs X also complained that the Health Board issued her with a response letter that did not address her recent complaint, and, instead, addressed an historic complaint from 2020. The Ombudsman decided that the Health Board should provide Mrs X with a written response (by 7 March) which should address her complaint. It should also include an explanation and an apology for the confusion and delay in its response. The Ombudsman considered this to be an appropriate resolution to the complaint instead of conducting an investigation.

Mrs X complained about the Health Board’s management of her chronic pain over the last year and about the unresolved issue of arranging a regular prescription of Lidocaine patches which has caused her pain and impacted on the quality of her life. Mrs X had complained to the Health Board but had not received a response to her concerns. The Health Board agreed to take action to resolve Mrs X’s complaint, namely: • To provide Mrs X with a response to her complaint to confirm the plan moving forward regarding the Lidocaine patches, provide Mrs X with the necessary details about the plan and apologise to her for the confusion and delays she has experienced regarding her prescription and appointment with her Consultant • To confirm an appointment for Mrs X with her Consultant. The Ombudsman was satisfied that the action the Health Board agreed to take would resolve the complaint.

Mr P complained that Cardiff and Vale University Health Board did not manage a neurodevelopmental referral in respect of his daughter, B, appropriately. He was also concerned that the Health Board had failed to provide him with adequate information about the referral process and B’s place on the waiting list. In response to the Ombudsman’s investigation, the Health Board said that it had offered B an assessment appointment and indicated that it was willing to provide further information to Mr P in the interests of resolving his complaint. The Health Board agreed to write a letter to Mr P to address a number of outstanding questions about B’s care specified by the Ombudsman and to apologise for previous inconsistent communication. It agreed to submit the letter to the Ombudsman for approval within 4 weeks and to issue the letter to Mr P within 1 week of receiving approval. The Ombudsman considered the complaint settled on the basis of the above actions.

Ms X complained that Cardiff and Vale University Health Board failed to properly investigate an allegation that she was sexually assaulted, whilst an inpatient. She said that the lack of duty of care had resulted in her mental state being compromised. The Ombudsman found that although the Health Board had provided several responses to Ms X’s complaint, it had not specifically addressed the decision not to report the incident to the police, the apparent delay in making a safeguarding referral and whether its decisions were in keeping with its safeguarding policy. The Ombudsman sought and gained the Health Board’s agreement to provide a further written response to Ms X within 20 working days, explaining its decision not to report the incident to the police, the apparent delay in making a safeguarding referral and whether its actions were in keeping with its safeguarding policy.

Mr B raised numerous complaints on behalf of his late mother, Mrs A, about her care and treatment over the course of 3 admissions to the University Hospital Llandough (“the Hospital”) between August and October 2019. The Ombudsman found that Cardiff and Vale University Health Board (“the Health Board”) failed to provide appropriate standards of nursing care because of a lack of individualised care planning, evidenced based interventions and regular nursing evaluation. Consequently, from the time of Mrs A’s second admission, appropriate steps were not taken to manage her longstanding leg ulcer and lymphoedema (blockage of the lymphatic system). In addition, there were no arrangements in place to provide continuity of ulcer care with the specialist pressure bandaging that was being applied in the community. This put Mrs A at increased risk of the serious deep tissue infections that she went on to develop. On Mrs A’s discharge from the second admission, an assessment for home care support failed to consider the previous level of input provided and her increased care needs. A reduced number of care visits was arranged leaving Mrs A’s family struggling to cope with an inappropriate level of support for 6 days before matters were addressed. Mrs A also had unmet nursing care needs during her final admission related to pressure and pain relief, personal hygiene and hydration. The Ombudsman also found that medical staff inappropriately delayed end of life care planning and communicating the incurable nature of Mrs A’s cancer diagnosis to her family until she was in the last few days of her life. When seeking her consent for participation in a medical study, the discussion with Mrs A was not recorded by medical staff as per the relevant guidance. Consequently, the Ombudsman could not say with certainty that Mrs A’s written consent was valid given the evidence that she was experiencing episodes of confusion at the time. The Ombudsman did not uphold complaints relating to the p

Ms A complained about the care and treatment that her late father, Mr B, received during his admission to the University Hospital of Wales between 19 July and 13 August 2020. The Ombudsman commenced an investigation but was subsequently informed by the Health Board that medical and nursing records for the episode of care had been mislaid and, despite extensive searches, could not be found. The Ombudsman regarded the loss of Mr B’s records as a concerning service failure which precluded the possibility of his conducting an investigation of Ms A’s complaint. The Ombudsman considered this an injustice to her and to her family and decided that it would be appropriate to discontinue Ms A’s complaint via a settlement. The Health Board subsequently agreed that, within 1 month, it would: •Provide Ms A with a fulsome apology for the loss of the records •Make a redress payment to Ms A of £1,000 in recognition of the injustice this matter gave rise to •Provide the Ombudsman with an account of the loss of the records, the attempts made to locate them and any measures it is considering and/or intending to introduce to minimise and hopefully prevent loss of records in the future. The Ombudsman considered that, in the circumstances, the Health Board’s actions were reasonable. Accordingly, he regarded Ms A’s complaint about the loss of records as settled.

Mrs H complained that a GP Practice (“the Practice”) in the area of the Cardiff and Vale University Health Board had failed to acknowledge or respond to her complaint which she had made to it by email in early October 2021. In settlement of Mrs H’s complaint, the Practice agreed to complete the following actions within 6 weeks of the Ombudsman’s decision: a) Apologise to Mrs H for failing to acknowledge or respond to her complaint. b) Provide its complaint response to Mrs H. c) Pay Mrs H £25 for her time and trouble in making her complaint to the Ombudsman.

Mr D complained about the care and treatment he received at the University Hospital of Wales during a scheduled admission for surgery to remove the right side of the colon. Mr D complained that: 1. Clinicians suggested that his diseased colon was the result of either Crohn’s Disease (“CD”) or appendicitis but never provided him with a definitive diagnosis. 2. Clinicians were slow to identify that he suffered a post-operative bleed and required further, emergency surgery. 3. Clinicians were aware that he suffered with Asperger’s Syndrome (“AS”) but failed to make appropriate adjustments to how information was conveyed to him. 4. Nurses who conducted home visits to assist Mr D in managing a temporary stoma provided inappropriate, ill-fitting stoma bags and unreasonably declined to obtain alternatives; they also failed to adequately treat excoriated skin around the stoma. The Ombudsman upheld complaint 1. The Health Board said that surgery was conducted on the presumption that Mr D had CD but that surgical findings later suggested complex chronic appendicitis. However, the Ombudsman, through his Surgical Adviser, found that Mr D’s pre-operative condition did not meet the threshold for surgery for either of these conditions. He also found (from the Surgeon’s intra-operative findings), that it should have been clear that there were no surgical grounds for removing even a limited amount of bowel tissue. The Adviser said that the risk to Mr D of performing surgery was not acceptable and that physicians should have employed a ‘watch and wait’ approach in which his condition would have settled without surgical treatment. The Ombudsman upheld complaint 2. He found that there was no record of observations taken for several hours after Mr D’s surgery and that a number of factors suggested that early diagnosis of his post-operative bleed may have been delayed. Though the Ombudsman accepted that it was not clear whether earlier identification of Mr D’s deterioration would have ch

Mr A complained that the Health Board failed to diagnose his skin cancer in a timely manner and that this delay caused the cancer to worsen and spread. The Ombudsman’s investigation found that, at the time Mr A was referred to the Health Board by his GP, it had been reasonable to conclude that, based on the referral information provided, Mr A had a basal cell carcinoma (a common form of skin cancer that slowly develops in the upper layers of the skin) and to manage it as such using the low-risk cancer pathway. When Mr A was reviewed by the Health Board’s dermatology clinic in person, a biopsy was taken which identified a stage 3 nodular malignant melanoma (a fast-growing type of skin cancer) and his care was appropriately expedited in a timely manner. Although there was a delay informing Mr A of his diagnosis, the Ombudsman accepted advice from his professional adviser that it was unlikely that this delay resulted in an adverse clinical outcome for Mr A. The complaint was therefore not upheld.

Mr X complained that the Health Board had failed to prescribe him a newly approved medication called Fampridine, a drug used to improve walking ability in patients with multiple sclerosis. Mr X said this resulted in him paying for private prescriptions when he should have received the treatment from the NHS. The Ombudsman found that the Health Board had not yet issued a Putting Things Right (“PTR”) response to Mr X’s complaint. However, since making his complaint, Mr X had been reviewed in the Health Board’s new Fampridine Clinic and Mr X now receives Fampridine on an NHS prescription. The Health Board agreed to an early resolution of Mr X’s complaint which included reviewing Mr X’s complaint and issuing a PTR response regarding his outstanding concerns within 4 weeks of this early resolution decision.

Mrs X complained that Cardiff and Vale University Health Board (“the Health Board”) had failed to undertaken an annual review of her son, as recommended by a private consultant. The Ombudsman found that the Health Board had refused to consider Mrs X’s complaint, submitted in May 2021, as it said that it had previously provided a response in December2019. The Ombudsman found that the December 2019 response addressed different issues and that Mrs X had not provided the Health Board with copies of correspondence from the private consultant in support of her complaint. The Ombudsman sought and gained the Health Board’s agreement to provide written confirmation within 10 working days to Mrs X that it would investigate her complaint about annual review of her son and respond in accordance with the NHS Putting Things Right process.

In November 2018 Mrs X attended Llandough Hospital, she was noted to have developed a left foot drop over the last 2 to 3 months. The foot drop corresponded with L4 (the fourth lumbar) and a previous MRI scan showed a disc prolapsed at L5/S1 (at the bottom of the vertical column). In December Mrs X had an urgent MRI scan that showed progressive degenerative changes to L5/S1. On 18 June 2019 Mrs X attended the Hospital, and she was referred for an Electromyogram (“EMG”). The 17 August EMG reported very severe acute and chronic radiculopathy. Mrs X complained about her treatment between September 2018 and August 2019. The Ombudsman found that an urgent decompression may have benefitted Mrs X, and she should have been assessed before November 2018. He also found that Mrs X had waited too long (7 months) for a consultation to discuss her urgent MRI result, the 21 June MDT had not explained her neurology when the MRI showed compression of the L5 nerve and the EMG, MRI scan and Mrs X’s symptoms were highly indicative of foot drop related to the L5 nerve root. The Ombudsman found that even by taking account of the pandemic, 23 months later, it was unreasonable that Mrs X had not been given the result of the EMG. The Ombudsman also found that Mrs X should have had more urgent assessments and investigations. The Health Board agreed to implement the Ombudsman’s recommendations within 1 month and apologise to Mrs X for the identified failings, make a redress payment of £2,000, and inform Mrs X of the result of the August 2019 EMG. The Health Board agreed within 6 months to consider e-referrals, ensure patients who have urgent scans are seen within 1 month, ensure patients are given the EMG results in a timely manner, and reviews the Spinal MDT process to consider whether a different approach should be adopted to ensure decompression identification.

Mr X complained about the care and treatment he received from Cardiff and Vale University Health Board (“the Health Board”), that it had not provided an appropriate response to his concerns and he did not feel that he had been listened to. The Ombudsman found that Mr X’s concerns about his care and treatment were substantially out of time. However, in relation to complaint handling, the Ombudsman found that the Health Board had delayed by over 12 months, arranging an agreed meeting to discuss Mr X’s concerns. The Health Board had not provided Mr X with any updates and information about the terms of the meeting was contradictory. There was also a delay and lack of updates in completing an agreed literature review. The Ombudsman said that the Health Board’s complaint handling caused unnecessary delays and frustration for Mr X. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr X, pay him £250 redress, provide the outcome of the literature review and arrange the agreed meeting within 1 month.

On 16 September 2019 Mrs X attended the Practice and complained of pain to her tooth and that it smelt. On 18 September a porcelain crown was fitted to the left second premolar tooth (“the UL5”). Mrs X said that the “wrong tooth” was treated, she said that the left second premolar tooth (“the UL4”) should have been treated. Mrs X said that the Dentist had not explained the procedure. Mrs X said that a few days later the UL5 fell out. Mrs X complained that she has been left with a gap in her teeth, she now speaks with a lisp and is unable to smile or have photographs taken. Mrs X sought quotations for private dental work for restoration to the UL5 by an implant. The Ombudsman found that comparison of X-rays taken on 1 April 2020 and 16 April to those taken on 3 March 2021 corroborated that there was no problem with UL4. He found that UL5 was appropriately treated with a crown, the “wrong tooth” was not treated. The Ombudsman found that the uncertainty of treatment with Mrs X and UL5’s limited prognosis should have been discussed. He also found that Mrs X should have been presented with options – removal of the tooth, restoration with either a crown or a large filling, but a crown was preferable. He found that an implant is not provided by the NHS that only offers dentures. The Ombudsman upheld the complaint on the basis that options were not given to Mrs X. The Practice agreed to implement the Ombudsman’s recommendations within 1 month to apologise to Mrs X for the failings, ensure its dentists are reminded to discuss and consider treatment options, and to make a redress payment of £367 as a reasonable contribution towards a denture for UL5 (reflective of a percentage for treatment to the UL5 by denture only).