PSOW Individual Decisions

Mrs A complained that a GP Practice in the area of Cardiff and Vale University Health Board (“the Practice”) had failed to provide an adequate service to her as a patient. She stated that she had telephoned the Practice of numerous occasions over the past 9months, but her calls had never been answered by staff. The Ombudsman was concerned that she had not received a service from the Practice. He was also sympathetic to the Practice who appeared to have been in the process of employing new staff to meet the demands place on it. The Ombudsman contacted the Practice regarding the telephone response aspect of Mrs A’s complaint. The Practice agreed to: • Provide the names of two members of staff that Mrs A can contact via its telephone line, who will arrange a pre-appointment telephone consultation with a GP for her. It has agreed to do this within 20 working days of the date of this letter. The Ombudsman believes that this will resolve Mrs A’s complaint.

Mrs G complained about Cardiff and Vale University Health Board’s (“the Health Board”) care, treatment and actions following her daughter’s, Mrs D, endoscopic retrograde cholangiopancreatography (“ERCP” – an examination of the pancreatic and bile ducts using a thin tube with a light and camera on the end). Mrs G said it caused her daughter internal bleeding, further health complications, and led to her premature death 6 weeks later. The Ombudsman’s investigation found that whilst the ERCP procedure carried out by a Radiologist caused Mrs D to suffer a splenic bleed, which is a very rare occurrence, this was an accepted known risk of the procedure and Mrs D was made aware of this risk beforehand. The Ombudsman could find no evidence that the Radiologist was at fault. Finally, the Ombudsman concluded that whilst Mrs D’s splenic bleed complicated her subsequent treatment following her previous diagnosis of pancreatic cancer, timely and appropriate action was taken, especially when Mrs D suffered pulmonary embolisms. The Ombudsman did not uphold Mrs G’s complaint.

Ms C complained about her daughter, H’s, management and care by Cwm Taf Morgannwg University Health Board’s “(the First Health Board’s”) Child and Adolescent Mental Health Services (“CAMHS”), including what Ms C felt was an unreasonable delay in diagnosing her daughter’s Borderline Personality Disorder (“BPD”). Ms C also complained about a lack of support provided to her prior to 2018, and that CAMHS failed to respond to respond to a letter from her. Ms C further complained about H’s management and care by Cardiff and Vale University Health Board (“the Second Health Board”) which took over management of CAMHS on 1 April 2019. She said that the Second Health Board did not recognise that BPD could exist in children and was failing to help children in severe distress. Ms C also complained that there had been a lack of support provided to her. The Ombudsman found that the diagnosis of BPD is often not formally diagnosed in a person under 18. He found no undue delay in diagnosing BPD in H, and found that her management and care by the First Health Board met an appropriate standard. However, he found failings in care planning which adversely affected Ms C and her daughter, and to that extent he upheld the complaint. He found that whilst individual members of CAMHS staff made considerable efforts to support Ms C, the First Health Board failed to provide a Care Co-ordinator as a point of contact who could have provided her with an overview of H’s care. He also found that the First Health Board failed to inform the Second Health Board of the support Ms Chad been receiving from a practitioner who was not moving to the Second Health Board. The Ombudsman upheld the complaint about the support provided to Ms C, and he also found that the First Health Board should have responded to the letter she sent. The Ombudsman did not uphold Ms C’s complaint about the Second Health Board’s care and management of H from April 2019. He found that after April 2019, CAMHS did recognise BPD in H

13. Mrs X complained about the Health Board’s refusal to remove a ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) form from her medical records. She explained that she felt worried, particularly if it became necessary for her to be readmitted into hospital. The Ombudsman found that the decision about the appropriateness of CPR would usually be reviewed upon a further hospital admission. She had been informed that the DNACPR did not mean she would not receive all active treatment for a presenting condition, and if she was readmitted, she could make her wishes clear to the admitting team that she wished to be resuscitated. Regarding the removal of the DNACPR from the medical records, the Health Board were correct in saying that the medical records were legal documents which could not be altered in any way. The Ombudsman found no failings in the way in which the Health Board dealt with Mrs X’s request to remove the DNACPR form from her medical records. However, in acknowledging her concern about admission to hospital, the Ombudsman considered whether there was anything further that could be done to alert staff to review the DNACPR. The Health Board agreed to: • put a note on the Clinical Portal, the electronic records and Mrs X’s paper records within 30 working days from the date that the Ombudsman issued his decision

Ms Y complained on behalf of her late partner, Mr X, about the care and treatment he received from Cardiff and Vale University Health Board. In particular, Ms Y complained that the Health Board did not determine the cause of Mr X’s seizures in a reasonable and timely manner, that it unreasonably prescribed andadministered medication to him, that communication with Mr X and his family was poor, and that no assessment of capacity was completed with Mr X. The investigation found that there was a significant delay in reporting the results of Mr X’sfirst MRI scan, which was compounded by a delay in anyone acting on the results of that scan, resulting in a 12 week wait. Thereafter a second “urgent” scan was requested, but there was a delay of 2 weeks before the request was even entered on to the request system, resulting in an 8 week wait. This was unacceptable and amounted to a service failure, as well as the uncertainty causing Mr X a significant injustice, therefore the complaint was upheld. In relation to medication, the investigation found that the prescription of medication to Mr X was in line with normal practice, however due to lack of contact for Mr X, he was not able to discuss his concerns about his medication. The investigation did not uphold this element of the complaint. The investigation upheld Ms Y’s complaint that communication with Mr X and his family was poor, for the reason set out above, and because Mr X and Ms Y were told, incorrectly, that they would have outpatient appointments fairly quickly after Mr X’s discharge from hospital, when this was not the case. There were also concerns that Mr X was advised to contact his GP when specialist advice was required, there were significant delays in internal communication at the Health Board, and delays in complaint handling so that Mr X was not aware of the outcome of the complaint prior to his death, all of which caused him an injustice. The complaint that Mr X did not receive a capacity assessment was not

Mrs X complained about treatment she received for repeat infections of the Prolene mesh (a loosely woven sheet used as either permanent or temporary support for tissue during surgery) in her abdominal wall. The mesh was first inserted many years previously, and she had undergone several surgical procedures to remove bits of the mesh but Mrs X’s complaint centred on her clinical care between 2018-2019 and delays in treatment within that period. Her repeat infections meant that Mrs X’s wound, once excised and drained of fluid, was left open and, she said, often weeping into her clothing, which distressed her greatly. The investigation found that, overall, Mrs X’s clinical care was to a reasonable standard. Prolene mesh is often removed in pieces, when necessary, as it links to tissue in the interim, so is impossible to remove as a whole. When infection happens, it often proves difficult to resolve completely and so becomes chronic, as in Mrs X’s case. Whilst acknowledging Mrs X’s distress, leaving the wound open to heal is accepted good practice. The Adviser appointed by the Ombudsman to review Mrs X’s case was critical of one attempt to close the wound after draining the fluid in 2018, describing it as “inadvisable”. Due to Mrs X’s ongoing repeat problems by then it was likely she would still have continued to suffer them so this aspect of the complaint was not upheld. The investigation found that there had been an 8 week delay in Mrs X undergoing a further procedure in late 2018, despite her referral being urgent. This was caused by lack of clarity in the communication between 2 hospital departments and a delay in response from a clinician at another hospital (relating to another condition Mrs X suffered from). In the context of a procedure required urgently, and that her situation was causing Mrs X distress, this was an injustice to her. This aspect of delayed care was upheld. The Health Board agreed to the Ombudsman’s recommendations to (i) apologise to Mrs X for

Mrs M complained about the care provided to her son Mr D, who sadly died of cancer in April 2020. In relation to the Trust, she complained that: • A consultant clinical oncologist had not communicated Mr D’s prognosis appropriately and had not offered to obtain a second opinion. • There was a failure to manage Mr D’s care appropriately. In relation to the Health Board Mrs M complained that: • A multi-disciplinary team (“MDT”) meeting decided not to offer cancer surgery to Mr D and this decision was not reviewed. • Mr D was not offered appropriate cancer surgery and had no option but to undergo surgery privately. • The clinical management of Mr D’s care and handling of an Individual Patient Funding Request by a hepatobiliary and pancreatic surgeon was inadequate. The investigation found that the Consultant Clinical Oncologist communicated Mr D’s prognosis reasonably and that it was not inappropriate that she did not seek a second opinion of the MDT meeting decision. The investigation found no evidence that the care provided by the Trust was inadequate. Accordingly, the Ombudsman did not uphold the complaints against the Trust. In relation to the Health Board, the investigation found that the MDT decision should have been reviewed and that this failure caused Mr D to lose confidence in the local Surgical Team; this complaint was therefore, upheld. The investigation found that in response to a privately obtained second opinion, the Health Board offered appropriate liver surgery. Accordingly, this aspect of the complaint was not upheld. In relation to the third complaint, the investigation found that the Health Board should have sought the input of a stereotactic body radiotherapy specialist and that it was an injustice that Mr D did not get to consider this advice. This aspect of the complaint was therefore upheld. In response to the Ombudsman’s investigation, the Health Board agreed to apologise to Mrs M and to pay her the cost of the private consultation to obtain a

Miss A complained that Cardiff and Vale University Health Board (“the Health Board”) had failed to carry out appropriate diagnostic tests when her mother had attended hospital on several occasions after she had suffered a heart attack in 2019. Miss A stated that the medical staff that had overseen her mother’s care during this time had also rejected the option of heart bypass surgery. Her mother had been examined privately and stated that the medical professional responsible for her consultation had advised her that heart bypass surgery should be considered. The Ombudsman considered the information available to him and was concerned that the Health Board did not appear to have provided Miss A’s mother with the offer of a second opinion. He, therefore, contacted the Health Board. The Health Board agreed to: 1) Arrange an appointment with one of its Consultants, her mother had not previously seen. 2) This Consultant will provide a second opinion whether heart bypass surgery is a reasonable option for her mother’s condition. It agreed to arrange an appointment for her mother to attend within 12 weeks of this decision letter and advise her mother of the date of the appointment when confirmed.

Mr X’s complaint concerned the care that was afforded to his late father by Cardiff and Vale University Health Board (“the Health Board”) in December 2020. Whilst the Health Board had responded to the initial complaint made by a family member in January 2021,he remained dissatisfied. He explained to the Ombudsman that the Health Board’s response had caused him to ask more questions which he outlined in a document titled ‘Cardiff and Vale University Health Board Concern’. The Ombudsman took into account that the Health Board had provided a response in April 2021 to the initial complaint raised by Mr X’s family member. However, the Ombudsman concluded that it would be helpful for the Health Board to provide a written response in relation to the further questions raised by Mr X. Following a discussion with the Health Board, it agreed to undertake the following in settlement of the complaint. The Health Board agreed to provide Mr X with a written response to the questions outlined in the document titled ‘Cardiff and Vale University Health Board Concern’ within 30 working days from the date that the Ombudsman issues his decision.

Ms D complained about the treatment she received at the Emergency Department (“the ED”) of the University Hospital of Wales (“the UHW”) when clinicians misdiagnosed an injury that she sustained to her left ankle following a fall. Ms D complained that, after reviewing an X-ray, an Emergency Nurse Practitioner (an ENP) diagnosed and treated her injury as a Grade II sprain. However, an X-ray report, which was not seen by ED clinicians until several days later, confirmed that she had sustained an undisplaced fracture to the tip of the lateral malleolus (the bony prominence on the outer edge of the ankle). Ms D complained that it was several weeks before she was informed of this misdiagnosis and that, during this time, the pain and swelling increased to the point where her GP referred her for a further X-ray, which confirmed the fracture. Ms D complained that, as a result of this, her recovery was delayed. The Ombudsman did not uphold Ms D’s complaint that the misdiagnosis led to her recovery being delayed. Whilst he established that the misdiagnosis did occur (and asked the Health Board to reflect on this), he was satisfied that the treatment for this type of fracture and a Grade II sprain are the same (as are the recovery time and prognosis). Given this, there was no evidence that the misdiagnosis led to any adverse clinical consequence. However, the Ombudsman found that the Health Board was slow to identify that a misdiagnosis had occurred and failed to ensure that Ms D was explicitly informed of this. Whilst it wrote to her recommending a physiotherapy follow-up, it did not inform her of the reason for this, nor did it ensure that the physiotherapist was made aware of the matter. The Ombudsman considered that clinicians failed to observe their duty of candour (in accordance with GMC Guidance) and that this, together with the additional inconvenience to Ms D of having to reattend the UHW, was an injustice to her. The Ombudsman also concluded that failings in the Healt