PSOW Individual Decisions

Mrs X complained about care and treatment provided to her son during his admission to hospital from December 2021 to March 2022. Specifically, her complaint related to the fact that prior to his admission to hospital, her son’s skin was intact. However, during his admission he developed suspected pressure sores, and, upon discharge, he was unable to walk unaided, and community nursing was required to attend to dress and treat the sores for a period of 3 months. The Ombudsman found that the Health Board’s complaint response to Mrs X had not adequately addressed her concerns about how/why her son had developed the sores. The Health Board had failed to make enquiries with its relevant departments to try to identify the cause of the sores, and in doing so, failed to identify whether Mrs X’s son required any ongoing treatment. She also found that the Health Board had not included reference to the safeguarding investigation, or its outcome, instigated when Mrs X’s son was admitted to Morriston Hospital in March 2022. Finally, the Ombudsman was concerned that there was an apparent failure to arrange community nursing care for Mrs X’s son, prior to his discharge. The Ombudsman contacted the Health Board and in resolution of Mrs X’s complaint it agreed to, within 20 working days, provide a further written response to her, which addressed the outstanding issues as detailed.

Mr A complained about the delay in his late wife, Mrs A’s, cancer diagnosis. Specifically, his complaint queried: whether Mrs A’s treatment by the Rheumatology department of the Health Board was appropriate, whether Mrs A’s complaints of rib pain were investigated appropriately by her GP Practice, whether the Practice’s prescription of antibiotics after Mrs A’s self-discharge from hospital was appropriate, and whether opportunities were missed by both bodies to diagnose her liver cancer earlier. The investigation found that the investigations undertaken by both the Health Board and GP Practice were appropriate, and their diagnosis of rib pain/costochondritis for the pain Mrs A suffered was reasonable. It did not find evidence to suggest that there were missed opportunities for either body to have suspected liver cancer as a cause for the pain. It found that the Practice appropriately treated Mrs A’s symptoms, including trying several different forms of pain relief. It found the prescription of antibiotics to Mrs A (including the type of antibiotics prescribed and delay in prescribing them until discharge information was received from the hospital) was appropriate. The complaints were therefore not upheld.

Miss L complained that Swansea Bay University Health Board had not responded to a complaint she made to it in April 2022. The Ombudsman concluded that the Health Board had failed to comply with its statutory complaint’s procedure and had not kept Miss L updated with its investigation. She said this caused frustration for Miss L. As an alternative to an investigation, the Ombudsman sought and gained the Health Boards agreement to apologise to Miss L for the delays, provide her with a formal response, and a time and trouble payment of £250 within 30 working days.

Mr A’s complaint centred on his care and management at Morriston Hospital (“the Hospital”). He complained that the Swansea Bay University Health Board (“the Health Board”) failed to accurately diagnose giant cell arteritis (“GCA” – inflammation in the lining of the arteries especially in the temple) and provide timely treatment following his visit to the Emergency Department (“ED”) on 21 February 2021. The Health Board also failed to inform Mr A that it did not offer a temporal artery biopsy (a procedure to remove a section of the artery for testing) to rule out GCA despite him being told in the ED it would be done urgently. Mr A said that the Health Board did not monitor his blood infection marker and manage his medication (prednisolone) in line with national guidance and that his GP was not informed of his management plan. Finally, Mr A said that the Health Board did not provide a robust complaint response. The Ombudsman’s investigation concluded that Mr A was diagnosed with GCA when he attended the ED in February, the medication was started and he was monitored as recommended by national guidance. The Ombudsman, having considered evidence, found no reason to believe that Mr A’s GP was not informed about his management. The Ombudsman welcomed the Health Board’s introduction of a new IT system which would enable seamless access to patient records. For these reasons the Ombudsman did not uphold these aspect of Mr A’s complaints. The Ombudsman was satisfied with the explanation provided by the Health Board about how suspected GCA’s are managed. The investigation however, found shortcomings in communication with Mr A about the unavailability of such biopsies, as he had been given contrary information that he would require an urgent biopsy. The Ombudsman concluded that the Health Board’s failure to update Mr A regarding biopsies was an injustice caused to him and his family as this unnecessarily prolonged additional stress and anxiety which could have been avoided. The

Mr X complained about the care and treatment provided to his late father during a hospital admission in April 2022. The Health Board had issued a formal written response, but Mr X later obtained a copy of his father’s health records which caused further concerns to be raised. The Ombudsman decided that it would be beneficial for Mr X to receive a further response from the Health Board. As an alternative to investigating the complaint, the Ombudsman made recommendations which the Health Board agreed to implement. The Health Board agreed to meet with Mr X to address the further concerns about his father’s care. It agreed to contact Mr X within five working days of the Ombudsman’s decision, to establish a convenient date to convene the meeting.

Mrs L complained that staff in Morriston Hospital’s Intensive Therapy Unit (ITU) failed to administer appropriate sedation and oxygen to her daughter, Ms J, to ensure she was comfortable and free from distress in the final hours of her life. The Ombudsman noted that Ms J, who had previously undergone a double lung transplant at an English Hospital, attended Morriston Hospital’s Emergency Department with deteriorating symptoms and increasing shortness of breath. Ms J was transferred to the Intensive Therapy Unit (ITU) for high flow nasal oxygen treatment (the delivery of higher flow levels of oxygen than can be achieved using a simple face mask). The Ombudsman noted that, following advice from the English Hospital that her condition was not amenable to treatment, Ms J was placed on an End-of-Life pathway with medication to treat anxiety, agitation and pain being prescribed. The Ombudsman also noted that an End-of-Life Care Plan was completed which stated that monitoring of vital signs and oxygen therapy were to be stopped and ventilatory support withdrawn. The Ombudsman found that the End-of-Life medication prescribed and administered to Ms J for symptom control was appropriate. However, prior to starting on the End-of-Life pathway, Ms J had been heavily dependent on oxygen and struggling to breathe. The Ombudsman considered it could have been predicted that Ms J might experience breathlessness when the high flow nasal oxygen was removed, and that if a clear plan had been put in place to address the potential need to reinstate oxygen therapy, a distressing episode, when Ms J became severely agitated and distressed, might have been avoided. The Ombudsman found that the Health Board failed to manage the withdrawal of Ms J’s oxygen appropriately, causing suffering and distress to Ms J as well as distress to her family who witnessed these upsetting events. The Ombudsman also found that it would have been good practice for an ITU doctor to review Ms J, although she acknow

Ms A complained that Swansea Bay University Health Board had failed to respond to the complaint she made to it in March 2022. The Ombudsman found that the Health Board had failed to respond to the complaint, had not proactively updated Ms A and had not managed her expectations. She said that this caused delays and frustration for Ms A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms A, pay her redress of £50, and to provide its complaint response to Ms A within 6 weeks.

Mr X complained that an Out of Hours GP employed by the Health Board provided him with incorrect advice and said he should have been referred to hospital. He also complained that the Out of Hours GP was dismissive in his attitude and his concerns were not addressed. The investigation found that the Out of Hours GP’s assessment of Mr X was reasonable and so was his management of Mr X at the consultation. However, the investigation also found that maladministration occurred during the Health Board’s handling of Mr X’s complaint and so it did not reach a reasonable standard. The Ombudsman upheld Mr X’s complaint that the Health Board did not handle his complaint properly. The Health Board agreed to the Ombudsman’s recommendation to apologise to Mr X.

Ms L complained that the staff at Swansea Bay University Health Board acted unprofessionally and inappropriately when she was required to undergo an MRI scan in November 2022. She further complained that the Health Board failed to follow the statutory complaints procedure and failed to take appropriate action in regard to her concerns. The Ombudsman decided that the Health Board had not yet fully responded to Ms L’s concerns and that there was further information to be shared with her. She said that this caused frustration to Ms L and there had been a breakdown in communication. As an alternative to an investigation, the Ombudsman sought and gained the Health Boards agreement to provide Ms L with full response and share any further information regarding the matter within 30 working days.

Mrs X complained that Swansea Bay University Health Board had performed an operation to remove her mother, Mrs Y’s, knee replacement, and replace it with a temporary implant to aid the treatment of her infected knee, without the facilities to carry out the second stage procedure to fit a permanent knee replacement. Mrs X complained that her mother had been left in a worse position than if she had not had the first operation, and without any indication when the second operation may take place. The investigation was discontinued as Mrs Y has now had the second operation to fit the permanent knee replacement which resolved her complaint and achieved the outcome she desired. The Ombudsman, having taking into account what Mrs X had to say and the available evidence, concluded that the investigation should be discontinued as it would not be proportionate to continue.

Mr F complained that he was dissatisfied with Swansea Bay University Health Board’s response to his complaint about his mother’s inpatient care and treatment. The Ombudsman found that there was a delay and miscommunication in the handling of Mr F’s complaint. The Health Board had not provided Mr F with a timeframe for conclusion of the case or its decision regarding redress. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr F and notify him of the timeframe for completion of his case within 10 working days, and to provide a final response within 4 months.

Mrs X complained that Swansea Bay University Health Board had performed an operation to remove her mother, Mrs Y’s, knee replacement, and replace it with a temporary implant to aid the treatment of her infected knee, without the facilities to carry out the second stage procedure to fit a permanent knee replacement. Mrs X complained that her mother had been left in a worse position than if she had not had the first operation, and without any indication when the second operation may take place. The investigation was discontinued as Mrs Y has now had the second operation to fit the permanent knee replacement which resolved her complaint and achieved the outcome she desired. The Ombudsman, having taking into account what Mrs X had to say and the available evidence, concluded that the investigation should be discontinued as it would not be proportionate to continue.

Mrs X complained about the Health Board’s handling of her complaint about her mother’s fall at hospital and her clinical care. Although the Health Board was continuing to consider the care element under the PTR redress provisions, and had provided Mrs X with some information, she had heard nothing further. Mrs X was also concerned to learn that some of her mother’s nursing records were missing, and how this might impact on the investigation. She asked the Ombudsman to consider her concerns about this and the lack of update from the Health Board. The Ombudsman was particularly concerned to learn about the missing records, given this had been highlighted as an issue across Wales through an earlier thematic report issued by the Ombudsman. She was also concerned at the lack of any update to Mrs X. Both lost records and lack of an update represented an injustice to Mrs X. As an alternative to investigating the complaint, the Ombudsman made recommendations which the Health Board agreed to implement. The Health Board agreed to apologise to Mrs X for the lost records, offer her redress of £500 for the delayed answers and frustration this had caused, and provide an update on the redress investigation and information about its communication task force’s work that it had previously noted. All these actions would be within 1 month. The Health Board further agreed to continue to undertake a search for the missing records and to consider whether a referral should be made to the Information Commissioner’s Office about the lost data. It also agreed to review and update its records management policies and processes to seek to avoid future loss, and to undertake that review within 3 months.

Mr A complained to the Ombudsman regarding issues with Swansea Bay University Health Board’s treatment of his prolonged penis discomfort following a flexible cystoscopy into his bladder. Mr A was unhappy that the Health Board advised his symptoms were long-standing dating back to2013, despite medical records showing no treatment in respect of this since2016. The Ombudsman found that there was contradiction between the Health Boards response that Mr A’s prolonged penis issue was long-standing and Mr A’s position that he had not had treatment since 2016. Medical records confirmed that there had been no treatment between 2015 and 2021. The Ombudsman was not satisfied that the Health Board’s response to Mr A was accurate. The Ombudsman sought and gained the Health Board’s agreement to, within 20 working days, provide Mr A with a full apology, to acknowledge that his discomfort was a ‘reactivation of long-standing symptoms’ and to provide Mr A with an explanation for this error.

Mr W complained that, during 2 admissions to Singleton Hospital in January and February 2020, staff failed to carry out appropriate investigations to diagnose his wife’s brain tumour. The Ombudsman noted that, on her first hospital admission, Mrs W had been referred by her GP because she was tired, had pain in the head and had felt off balance and had been dropping things. Whilst medical staff diagnosed hypercalcaemia (raised blood calcium) which was thought to be caused by Vitamin D supplements, the Ombudsman found that Mrs W had symptoms that could not be attributed to hypercalcaemia and that a brain scan should have been carried out. The Ombudsman found that when Mrs W was readmitted to hospital with worsening symptoms 10 days after discharge, a CT scan (the use of X-rays and a computer to create an image of the inside of the body) was appropriately done. However, the result of the scan were ambiguous, and the Ombudsman considered that it should have triggered a further scan. This was not done, and Mrs W was discharged from hospital for further specialist review. The Ombudsman found hat, as a result, Mrs W’s brain tumour was not diagnosed until she was readmitted to hospital 13 days later. The Ombudsman found it very likely that if brain scans had been carried out during Mrs W’s first hospital admission, her brain tumour would have been diagnosed an earlier stage. Sadly, however, earlier diagnosis would not have affected the outcome as Mrs W’s brain tumour was aggressive and not amenable to treatment. Nonetheless, the Ombudsman found that the delay in diagnosis led to worry and distress both to Mrs W and her husband, which was a significant injustice to them. The Ombudsman upheld the complaint. The Ombudsman recommended that the Health Board apologise to Mr W for its failings. She also recommended that it share her report with medical staff to highlight the failings identified and ensure that lessons are learnt, and to provide evidence that it had done so.

Mrs T complained that the Dental Practice wrote to her and informed her that she had been removed from its patient list on the basis she had been rude and aggressive. Mrs T further complained that despite her writing to the Practice to reconsider the decision, she had not received a response. The Ombudsman was concerned that Mrs T had not yet received a responds to the concerns raised and therefore contacted the Practice. The Practice explained that there was a new Practice Manager at the Dental Practice and that she was not in post when Mrs T was removed from the practice list. As an alternative to an investigation, the Practice agreed to respond in writing to Mrs T’s complaint and provide her with options about her continuing dentalcare within 30 working days

Mr B complained that Swansea Bay University Health Board failed to diagnose his Spigelian hernia in a timely manner and this led to a delay in the procedure carried out. The investigation was discontinued as Mr B was given a date for the procedure which he felt offered some resolution of his complaint. The Ombudsman, having taken into account what Mr B had to say and the available evidence concluded that the investigation should be discontinued as it would not be proportionate to continue the investigation.

Mr X complained that he had not received a response from the Practice following the complaint he made in March 2022 regarding the care and treatment he received for his shoulder pain. The Ombudsman found that the Practice had failed to provide regular and meaningful updates and had not issued its complaint response. The Practice agreed to complete the following in settlement of Mr X’s complaint within 4 weeks, as an alternative to the Ombudsman investigating it: a) Write to Mr X with an apology for the failure to provide regular and meaningful updates b) provide an explanation for this oversight c) Issue a complaint response.

Ms A complained that Swansea Bay University Health Board failed to respond to her concerns raised in 2021, about the progression of her care and treatment, communication with her and her involvement in the planning and decision-making process. The Ombudsman considered that aspects of Ms A’s complaint remained outstanding. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to within 30 working days, provide a complaint response for the outstanding issues.

Mrs A complained about care and treatment provided to her late husband in December 2020 and January 2021. She was unhappy that he was examined in the car park, was not prescribed further medication or offered oxygen and was not referred to hospital. Mrs A did not accept the explanations provided by the Practice. The Ombudsman found that the care provided by the Practice was within the range of appropriate clinical practice at the time and that the explanations given were reasonable. The Ombudsman was concerned that Mr A had not been invited for apneumococcal vaccine, which he was entitled to due to his age and health conditions. The Practice appeared to have an ad hoc system for offering such vaccinations when patients attended. The Ombudsman sought and gained the Practice’s agreement to, within 20 working days, provide Mrs A with an apology for its failure to offer Mr A the pneumococcal vaccination and to review the Practice’s procedures for offering pneumococcal vaccination to patients and consider whether the approach is adequate, particularly in light of the pandemic and reduced face-to-face contacts with patients.

Ms X complained to the Ombudsman about aspects of the care provided to her father as an inpatient. She also raised a concern about how her complaint had been handled by the Health Board. Having carefully considered the aspects of the complaint, the Ombudsman decided not to investigate the specific points of complaint raised. However, the Ombudsman did note that there was a lack of clarity on one aspect (transfer of records) of the complaint response provided by the Health Board. In recognition of this, the Health Board agreed to: • Provide Ms X with a written apology for the lack of clarity in its complaint response relating to the transfer of records. • Make an ex gratia payment of £250 to Ms X for any additional distress caused by this error. The Health Board agreed to do this within 6 weeks of the date of this letter.

MrsX complained that despite her requests, the Nursing Home had failed to arrangea face-to-face meeting with her to address her outstanding concerns about thecare provided to her parents when they resided at the Nursing Home. In considering the complaint, the Ombudsman was concernedthat a meeting had not taken place despite assurances that a meeting would befacilitated once Covid-19 restrictions had been lifted. In making enquiries with the Nursing Home, theOmbudsman was informed that the Nursing Home was in the process of beingdissolved and therefore a meeting would now be unfeasible. In view of the situation, the Ombudsman asked the Nursing Home,upon receipt of Mrs X’s outstanding questions, to provide a written responsewithin 1 month.

Mrs X complained that she had not received a response form the Health Board following her complaint about the care and treatment provided by an Orthopaedic Surgeon which she made to the Health Board in August 2021. The Ombudsman found that the Health Board had failed to provide regular and meaningful updates and had not issued a complaint response. The Health Board agreed to complete the following in settlement of Mrs X’s complaint by 25 August 2022, as an alternative to the Ombudsman investigating it: a) Write to Mrs X with an explanation and apology for the failure to provide regular and meaningful updates b) Explain the delay in providing a complaint response c) Issue its complaint response d) Pay Mrs X £250 for her time and trouble in pursuing her complaint with the Health Board and the Ombudsman.

Mrs X complained about the lack of communication from the Health Board regarding the care provided to her husband and his prognosis. She said that this meant that she was unable to spend her husband’s last moments with him. The Ombudsman found that there were failings in the Health Board’s communication with Mrs X. She sought the Health Board’s agreement to improve its communication with relatives, particularly in relation to end of life care. The Health Board agreed to take a number of actions to remind staff about the importance of inviting relatives into the Emergency Department. This included the use of posters as prompts for staff to speak to family if the patient had a DNAR (do not attempt cardiopulmonary rescusitation) decision in place or had been commenced on the end of life pathway. The Health Board agreed to provide evidence that it had carried out these actions within 20 working days.

Mrs A complained about the care and treatment provided to her mother, Mrs B, by the Health Board. Specifically, she complained that: a) The Health Board failed to appropriately investigate and treat the cause of Mrs B’s knee pain following her arrival at Morriston Hospital (“the First Hospital”) on 27 January 2021 b) The transfer of Mrs B to Neath Port Talbot Hospital (“the Second Hospital”) on 1 March 2021 was unsafe. The Ombudsman’s investigation found that the Health Board had failed to carry out appropriate investigations in response to Mrs B’s ongoing, unexplained knee pain and decline in mobility. This was a service failure. As a result, the diagnosis of Mrs B’s dislocated knee was delayed by several weeks and Mrs B lost the opportunity to receive earlier treatment which could potentially have significantly improved her mobility and relieved her pain. This was a serious injustice. Accordingly, the Ombudsman upheld complaint a) The investigation also found that, whilst the transfer to the Second Hospital was not clinically unsafe, Mrs B should not have been transferred before appropriate investigations of her knee had been carried out. Therefore, complaint b) was upheld to the limited extent that Mrs B was deprived of care which could potentially have avoided the need for a transfer. The Ombudsman recommended that the Health Board should apologise and make a payment of £1,000 to Mrs A in respect of the injustices arising from its failings. She also recommended that the Health Board should remind relevant clinical staff of the importance of documenting multidisciplinary discussions and of carefully reviewing radiology reports, and that it should produce an action plan to address other significant failings. The Health Board agreed to implement the recommendations.