Ombudsman finds patient received substandard medical and nursing care at a north Wales hospital

Betsi Cadwaladr University Health Board (BCUHB) neglected to provide appropriate medical and nursing care to a patient with bowel care needs, who later passed away, a public services watchdog has found.

A report published today, Thursday, April 19, by the Public Services Ombudsman for Wales has revealed that a 60-year-old patient who was born with spina bifida – referred to as Ms B -received substandard medical and nursing care at a north Wales hospital.

The Ombudsman launched an investigation after Mrs A complained about the care her sister, Ms B, received from BCUHB when in Ysbyty Glan Clwyd between May 2019 and May 2020. Ms B sadly died in May 2020.

Ms B, who used a wheelchair, had a history of kidney problems and needed regular manual bowel evacuations carried out by the District Nursing Team.

In 2019, Ms B was under the care of a consultant urologist, who performed a nephrostomy procedure to improve her kidney drainage.

However, she experienced post-surgical complications and hospital admissions due to issues with her nephrostomies.

In 2020, Ms B had four hospital admissions, during which she suffered from breathing difficulties, type 2 respiratory failure, and ongoing respiratory issues related to pneumonia.

During one admission, Mrs A, informed the nursing staff about Ms B’s bowel evacuation needs.

Despite this, the nursing staff were unable to perform the procedure, and there is no record of a follow-up.

Despite new symptoms suggesting a bowel blockage but she was discharged without the symptoms being considered.

When Ms B complained of severe pain and loose stools, her symptoms were attributed to antibiotics.

Ms B was readmitted with possible sepsis, heart-related issues, and type 2 respiratory failure.

Despite treatment, her condition deteriorated rapidly, and she died.

The cause of death was identified as acute and chronic respiratory failure, restrictive air capacity in the lungs due to her disability, fluid build-up in the brain, and kidney disease.

Following a complaint from Mrs A, the Health Board acknowledged their failure to provide adequate bowel care and discharge Ms B when she should not have been.

However, they maintained that these failings did not contribute to her death.

The Ombudsman’s investigation revealed several shortcomings in the medical and nursing care received by Ms B, which ultimately led to her avoidable pain, discomfort, and compromised dignity.

The patient, referred to as Ms B, was a 60-year-old wheelchair user with long-standing health conditions, requiring regular care from a nursing team.

Mrs A, filed a complaint regarding delays in kidney treatment and inadequate bowel care, alleging that no skilled staff were available to administer necessary treatment.

The Ombudsman’s investigation concluded that Ms B’s kidney treatment was reasonable.

The Ombudsman found that Ms B’s kidney treatment was reasonable.

However, she was very concerned that Ms B did not receive the right bowel care and that she was discharged home without being seen by a doctor after she developed new symptoms.

The Ombudsman also found that the Health Board’s own investigation into Mrs A’s complaint was not thorough or open enough.

In addition, she found that the record keeping by the Health Board fell short of the requirements expected for both doctors and nurses.

Public Services Ombudsman for Wales, Michelle Morris, offered condolences to Ms B’s family and expressed concern about the failures in medical and basic nursing care.

Ms Morris said: “I would firstly like to offer Mrs A and her family my sincere condolences. I recognise that they will find much of the detail in this report distressing.”

“It is clear from my report that there were shortcomings in medical and basic nursing care received by Ms B. I am concerned that although Ms B herself and Mrs A clearly informed the nursing staff of Ms B’s bowel care needs, that was not given the attention that it should have had – particularly given the possible serious medical consequences of not doing so.”

“We cannot say for sure that the fact that Ms B did not receive the bowel care she needed contributed to her death, as she was very unwell with other problems.  However, I have no doubt that the failings I have identified caused her avoidable and unnecessary pain and discomfort as well as compromised her dignity.”

“Ms B was in hospital during the early days of the COVID-19 pandemic.  We understand and acknowledge that these were difficult and uncertain times with stretched NHS resources. However, Ms B’s care was simply not of an acceptable standard.”

“The NHS in Wales is now bound by statutory Duty of Candour, requiring them to be open and honest with patients and service users when things go wrong. In my view, the initial review of Ms B’s care undertaken by the Health Board lacked depth, rigour, openness and transparency required by that Duty.”

“I am also very concerned that my office has identified similar problems of failings in basic nursing care, in record keeping, and in communication in previous cases we have investigated about this Hospital.”

The Ombudsman recommended that Betsi Cadwaladr UHB apologise to Mrs A, compensate her £4,500 for distress and pursuing the complaint, and share the report with the staff involved for reflection.

Additionally, the Health Board must remind nursing staff of proper record-keeping, complete a Bowel Care Protocol, train staff in manual bowel evacuation procedures, and review its complaint handling in light of the NHS Wales Duty of Candour set to be introduced in April 2023.

The Health Board has accepted the Ombudsman’s recommendations.

Dr Nick Lyons, BCUHB’s interim deputy CEO and executive medical director, said: “I would like to sincerely apologise again to this patient’s family for the distress caused both during her treatment and the period of their complaint.

“We acknowledge the Ombudsman’s report, accept all the recommendations in full and have made sure the lessons contained within it have been made clear to all staff involved.

“We can only gain the trust of the public we serve by being completely transparent about failings when they occur – and we are fully committed to that principle.”