PSOW Individual Decisions

The Ombudsman investigated a complaint from Mr Y about the way that a trainee GP at the Practice had managed the care of his late wife, Mrs Y, when she had contacted the Practice complaining of a history of 10 days constipation and abdominal pain. A telephone appointment was arranged with the trainee GP, who was of the opinion that Mrs Y was suffering from constipation as a result of low fluid intake. He did not arrange to see Mrs Y but told her that if she displayed any “red flag” symptoms she should attend the Emergency Department. Four days later Mrs Y was admitted to hospital and underwent investigations which identified that she had a bowel perforation in 2 places. Sadly, despite undergoing surgery, Mrs Y died 2 days later of multi-organ failure, sepsis and a perforated colon. The Ombudsman found that there was a failure to take clinically appropriate action and to arrange a face-to-face consultation with Mrs Y, based on the symptoms she presented with during the telephone consultation on 19 July 2021. It was considered, that on balance, a more thorough assessment or clinical examination may have changed the diagnosis of constipation or may have led to a consideration that Mrs Y was suffering from a more serious underlying cause for the constipation, that needed further investigation. The Ombudsman upheld the complaint and recommended that the Practice apologise to Mr Y, as it was responsible for the service being delivered to their patients. The Ombudsman did not identify an issue with the manner in which the trainee GP was being supervised. The Ombudsman would have made a number of recommendations to ensure that the trainee GP reflected and learned from this event to ensure the same shortcomings did not happen again. However, since Health Education and Improvement Wales had already ensured that all relevant actions had been undertaken as part of its usual processes, the Ombudsman was satisfied that no further recommendations were required to ensure future lea

Mrs B complained about the care and treatment that her late husband, Mr B, received from the Health Board and the Trust in 2020. In relation to the Trust, Mrs B complained that the Consultant Oncologist did not offer Mr B chemotherapy treatment, did not clearly explain the reasons for that decision, and did not tell Mr B that he had advanced cancer and stage 3 chronic kidney disease. In relation to the Trust and the Health Board, Mrs B complained that further referrals to the Trust for consideration of chemotherapy were not made or acted on at a time when Mr B was well enough to benefit from the treatment. In relation to the Health Board, Mrs B complained that there was an unreasonable delay in investigating and treating Mr B’s deep vein thrombosis, investigating Mr B’s enlarged lymph node and carrying out a biopsy following a referral by his GP. Mrs B also complained that she was not allowed to visit her husband in hospital when he was at the end of his life and that there was a delay in the Health Board responding to the complaint, as well as failing to arrange a meeting to discuss the complaint findings. The Ombudsman concluded that it was the Consultant Oncologist’s responsibility to ensure Mr B understood his illnesses insofar as they related to the risks and benefits of chemotherapy in order to demonstrate that decisions were appropriately made. It was determined that the risks of chemotherapy were not proportionately weighed against the benefits and, although the outcome for Mr B may not have been any different, chemotherapy should have been offered. This was an injustice to him and this complaint against the Trust was upheld. The Ombudsman did not uphold the complaint against both the Trust and the Health Board, that further referrals for chemotherapy were not made or acted upon. Some delays were identified in timescales for appointments and investigations prior to the further referral to oncology on 21 September but this would not have made a difference to

Ms C complained about the care and treatment her late mother, Mrs A, received from Velindre University NHS Trust (“the Trust”). Ms C complained about whether Mrs A’s consultation with the Trust on 29 December 2021 was timely and whether at this, and the consultation on 10 January 2022, her treatment and assessment were appropriate. Ms C also complained about whether the Trust’s palliative care input was appropriate. The Ombudsman found that the treatment and assessment during both consultations, and the Trust’s input in regard to palliative care, were overall, reasonable and appropriate. The Ombudsman did not uphold the complaint.

Ms A’s complaint related to the care and treatment that her late partner, Mr B, received from the Health Board and the Trust in 2020. Specifically, Ms A complained that there had been a delay in the Health Board confirming her partner’s diagnosis of lung cancer with a biopsy, and that both the Health Board and the Trust then failed to start his treatment immediately after this diagnosis was confirmed in September 2020. Following Mr B’s admission to hospital in October 2020, Ms A complained that a Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) form was inappropriately placed on her partner’s records and that the Health Board failed to provide him with appropriate care and treatment during the admission. Furthermore, Ms A raised concerns that she was denied the opportunity to visit Mr B before he died, despite being informed that he was “critically ill” and numerous family members then being allowed onto the ward after his death, and that the Health Board failed to provide her with regular updates on Mr B’s condition and did not contact her to inform her of his death. In addition, Ms A also raised concerns that her partner’s basic hygiene needs were ignored given that he died in the same clothes that he was admitted to hospital in 2 days beforehand. Ms A also complained about the accuracy and completeness of the Health Board’s complaint response. The Ombudsman concluded that although there were delays in confirming Mr B’s diagnosis with a biopsy, these delays were not due to any identifiable failings on the part of the Health Board and appropriate investigations into Mr B’s lung cancer had been undertaken in accordance with relevant guidelines. The Ombudsman also considered that the length of time between the confirmation of Mr B’s diagnosis and the proposed start date for treatment had been reasonable under the circumstances. As a result, the Ombudsman did not uphold these complaints. In terms of Mr B’s later admission to the Hospital, the investigation foun

Mr X complained that after his late wife’s discharge from hospital, he noticed that her wedding ring had been lost. Mr X further complained that the Trust’s policies and procedures were not followed in keeping his wife’s wedding ring safe and, instead of securing it in a safe, it was left on the bedside cabinet. The Ombudsman is not able to decide whether the Health Board is liable for Mr X’s late wife’s wedding ring. However, the Ombudsman identified that there was further action which the Trust could take. The Ombudsman contacted the Trust and it agreed to complete the following actions by 10 October 2022 in settlement of the complaint: remind relevant staff of its policies and procedures relating to patient property and to write to Mr X and ask him to liaise with it about a reasonable offer of compensation.

Mrs A complained that the GP Practice (“the Practice”) failed to provide satisfactory care to her mother, Mrs B, and that this contributed to her rapid terminal decline in April 2020. Further, Mrs A said the Practice’s handling of her complaint was not adequate or robust. Mrs A also complained about the community nursing care provided the Health Board and about a telephone consultation with an Out of Hours GP (“the OOHGP”) on 15 April. Finally, Mrs A complained about the Oncologist at Velindre NHS Trust (“Trust”) and their communication with the family as well as the Trust’s complaints handling. The Ombudsman’s investigation found that, broadly, the consultations by the GPs were appropriate and that Mrs B’s rapid decline and death could not have been anticipated. However, given Mrs B’s sudden deterioration, a face-to-face consultation would have been helpful, especially as it later delayed the family getting a death certificate. Although this shortcoming did not contribute to Mrs B’s sudden deterioration, or alter the sad outcome, it added unnecessarily to the family’s distress at a difficult time. The complaint against the GP Practice was upheld to this limited extent. The Ombudsman also found shortcomings in the record keeping by the District Nurses’ that failed to provide adequate handover information for continuity of care. Records were also added retrospectively after Mrs A had complained. Although the investigation concluded that a home visit by the OOHGP was not necessary following the telephone consultation, given that there was every indication that Mrs B was likely to be close to death, this should have been discussed with Mrs A so that she was better prepared. The Ombudsman found that these communication failings caused an injustice to Mrs A and the family as it added to their distress at a very difficult time and this aspect of the complaint against the Health Board was upheld. Please Note: Summaries are prepared for all reports issued by the Ombudsman.

Mrs A complained to the Ombudsman about the treatment her mother, Mrs B, received from Velindre University NHS Trust(“the Trust”), Cwm Taf Morgannwg University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”). Mrs B was diagnosed with a sarcoma (a rare type of cancer). She was referred to a specialist Sarcoma Multidisciplinary Team (“MDT”- a team comprising of specialist doctors and nurses who meet to establish a patient’s diagnosis and treatment). Mrs B underwent radiotherapy(the use of radiation to kill cancer cells), in preparation for surgery under a surgeon at the Second Health Board. A CT scan taken just before the surgery later showed that the disease had progressed. Mrs B remained under the care of the First Health Board, the Second Health Board and the Trust during the treatment of her sarcoma. It was later identified that the cancer had spread to her lungs and that this was considered to be uncurable. Plans for chemotherapy as a palliative measure was delayed because of the Covid pandemic. Sadly Mrs B died on 1 October 2020. The investigation looked at whether the Trust failed to communicate appropriately with Mrs B and her family; missed an opportunity for earlier treatment; and failed to treat a potential infection following a blood test result. The Ombudsman also considered whether the first Health Board failed to appropriately investigate the possibility of an infection following Mrs B’s admission to hospital. Finally, the investigation looked at Mrs A’s complaint that the second Health Board failed to inform her of abnormal lesions found on Mrs B’s CT scans and failed to treat those lesions. The investigation also considered whether the Second Health Board failed to provide appropriate post-operative physiotherapy care and whether it maintained Mrs B’s medical records to an appropriate standard. The investigation found that the clinical care provided by all three bodies was of an appropriate s

Mrs A complained to the Ombudsman about the treatment her mother, Mrs B, received from Velindre University NHS Trust(“the Trust”), Cwm Taf Morgannwg University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”). Mrs B was diagnosed with asarcoma (a rare type of cancer). She was referred to a specialist Sarcoma Multidisciplinary Team (“MDT”- a team comprising of specialist doctors and nurses who meet to establish a patient’s diagnosis and treatment). Mrs B underwent radiotherapy(the use of radiation to kill cancer cells), in preparation for surgery under a surgeon at the Second Health Board. A CT scan taken just before the surgery later showed that the disease had progressed. Mrs B remained under the care of the First Health Board, the Second Health Board and the Trust during the treatment of her sarcoma. It was later identified that the cancer had spread to her lungs and that this was considered to be uncurable. Plans for chemo therapyas a palliative measure was delayed because of the Covid pandemic. Sadly Mrs B died on 1 October 2020. The investigation looked at whether the Trust failed to communicate appropriately with Mrs B and her family; missed an opportunity for earlier treatment; and failed to treat a potential infection following a blood test result. The Ombudsman also considered whether the first Health Board failed to appropriately investigate the possibility of an infection following Mrs B’s admission to hospital. Finally, the investigation looked at Mrs A’s complaint that the second Health Board failed to inform her of abnormal lesions found on Mrs B’s CT scans and failed to treat those lesions. The investigation also considered whether the Second Health Board failed to provide appropriate post-operative physiotherapy care and whether it maintained Mrs B’s medical records to an appropriate standard. The investigation found that the clinical care provided by all three bodies was of an appropriate st

Mrs A complained to the Ombudsman about the treatment her mother, Mrs B, received from Velindre University NHS Trust(“the Trust”), Cwm Taf Morgannwg University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”). Mrs B was diagnosed with a sarcoma (a rare type of cancer). She was referred to a specialist Sarcoma Multidisciplinary Team (“MDT”- a team comprising of specialist doctors and nurses who meet to establish a patient’s diagnosis and treatment). Mrs B underwent radiotherapy(the use of radiation to kill cancer cells), in preparation for surgery under a surgeon at the Second Health Board. A CT scan taken just before the surgery later showed that the disease had progressed. Mrs B remained under the care of the First Health Board, the Second Health Board and the Trust during the treatment of her sarcoma. It was later identified that the cancer had spread to her lungs and that this was considered to be uncurable. Plans for chemotherapy as a palliative measure was delayed because of the Covid pandemic. Sadly Mrs B died on 1 October 2020. The investigation looked at whether the Trust failed to communicate appropriately with Mrs B and her family; missed an opportunity for earlier treatment; and failed to treat a potential infection following a blood test result. The Ombudsman also considered whether the first Health Board failed to appropriately investigate the possibility of an infection following Mrs B’s admission to hospital. Finally, the investigation looked at Mrs A’s complaint that the second Health Board failed to inform her of abnormal lesions found on Mrs B’s CT scans and failed to treat those lesions. The investigation also considered whether the Second Health Board failed to provide appropriate post-operative physiotherapy care and whether it maintained Mrs B’s medical records to an appropriate standard. The investigation found that the clinical care provided by all three bodies was of an appropriate s

Mrs G complained about her treatment for ovarian cancer between February and October 2020, specifically: • delay in discussing her prognosis with her and thereafter failure to fully discuss treatment options • incorrect information given to her regarding the suitability of different drugs • the completion and submission of an Independent Patient Funding Request form (“IPFR”). The Ombudsman found that the pre-chemotherapy appointment and completion of the consent form was a missed opportunity to explore Mrs G’s understanding of her condition and prognosis. He found that there had been some miscommunication or confusion over the suitability of different drugs for Mrs G and that she had been given unrealistic expectations of the treatment she might receive. The Ombudsman concluded that not enough thought had gone into the submission of the IPFR with the Consultant merely “copying and pasting” information Mrs G had provided, resulting in an application which was confused and not for the most appropriate medication. He upheld the complaint. The Ombudsman recommended that the Trust apologise to Mrs G and consider reviewing its chemotherapy consent forms; he also invited the Consultant to reflect on their communication with patients regarding their prognosis.

Mrs X complained about the care and treatment provided to her late husband. Mrs X said she felt her husband’s care was substandard due to a lack of surgery and poor communication. Mrs X also complained about the delay in the Health Board’s response following her complaint to it in April 2021. The Ombudsman decided that the Health Board should provide Mrs X with a comprehensive response to address her complaint (by 8 April). It should also provide Mrs X with an explanation and apology for the delayed response. The Ombudsman considered this to be an appropriate resolution to the complaint instead of conducting an investigation.

Mrs Y complained that Velindre University NHS Trust did not provide reasonable care and treatment to her son, Mr X, after March 2020. Mrs Y also complained that the Trust did not handle her complaint properly. The Ombudsman noted that the Covid-19 pandemic began to have a significant impact in the UK in March 2020. The Ombudsman found that Mr X had already received 2 combinations of chemotherapy by 10 February, and these had not been successful, so even before March 2020 there were limited options available to Mr X. All clinical trials were closed to new patients from March, so the only possible treatment option available to Mr X from that time was chemotherapy. Because Mr X had not reacted positively to 2 attempts at chemotherapy, he was prioritised as the lowest priority level to receive treatment, and the chances of him reacting well to a third attempt were remote. The Ombudsman accepted advice that it would have been reasonable not to have offered a third attempt at chemotherapy even without the pandemic, and that in light of the information about the impact of Covid-19 on chemotherapy patients coming from China and Italy, it was reasonable not to provide a third attempt at chemotherapy to Mr X in the circumstances. The complaint was not upheld. However, the Ombudsman found that communication with Mr X and his family was limited, and that after March 2020, the reasons for not providing further chemotherapy to Mr X were not clearly recorded. The Ombudsman upheld Mrs Y’s complaint that the Trust did not handle her complaint properly, because the Trust pushed for meetings inappropriately, sought additional consents when this was not required, sent an email to an incorrect email address, and did not advise Mrs Y of this data breach in a timely way. All of these errors occurred at a time when the family were grieving, which caused them distress and injustice. The Trust agreed to apologise to Mrs Y for the identified failings, and to confirm what safeguards it had put

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