Ombudsman Wales: Patient with learning disabilities failed by Betsi Cadwaladr University Health Board

A report published today by the Public Services Ombudsman for Wales has exposed significant shortcomings in the care provided by Betsi Cadwaladr University Health Board to a patient with learning disabilities.

An investigation was triggered following a complaint from the patient’s sister, referred to as Ms D within the report.

She highlighted multiple failures in the treatment and support of the patient – referred to as Ms A in the Ombudsman’s report  – who suffers from epilepsy, cerebral palsy, and learning disabilities.

Ms A was admitted to Wrexham Maelor Hospital in July 2022.

Ms A, who requires 24-hour care, experienced substantial failings in managing her pain, epilepsy, and basic personal care needs.

The Ombudsman’s report pointed to a lack of effective communication and support for Ms A, especially in the absence of her family and the Learning Disability (LD) team.

The investigation revealed that no person-centred nursing care plan was in place for Ms A, resulting in a lack of understanding of her needs among staff.

This issue was particularly evident during weekends and overnight shifts when Ms A’s care fell below acceptable standards.

The report highlighted that nursing staff failed to consistently identify and manage Ms A’s pain due to the use of inappropriate assessment tools.

This oversight left Ms A in unnecessary pain, relying on her family or the LD team to recognise her discomfort.

Substandard record-keeping

In terms of epilepsy management, the Ombudsman found that hospital staff’s record-keeping was substandard.

There were instances where Ms A’s seizures went unrecognised and unrecorded unless her family was present to alert the staff.

The administration of anti-seizure medication was also found to be inadequate, potentially contributing to an increase in Ms A’s seizure activity.

Ms D provided detailed evidence of these failings, including occasions where Ms A was left in soiled bedding and unsupported at mealtimes and with personal care.

She also pointed out instances where staff struggled to understand Ms A’s communication needs, leading to further distress.

Michelle Morris, the Public Services Ombudsman for Wales, expressed deep concern over these findings, stating, “The evidence I have found shows that Ms A was at times in pain, which was not only distressing for her but for her family as well. It concerns me that Ms A would likely have been very frightened when alone in hospital without family present, and experiencing pain. Additionally, the lack of record-keeping in relation to Ms A’s seizures is not only dangerous but also represents a poor level of care.”

The report also criticised the Health Board’s handling of the initial complaint, stating that the response to Ms A’s sister fell significantly short of the NHS Wales Duty of Candour.

Although this duty was not in force at the time, the Health Board was expected to respond with greater transparency and honesty.

In response to these findings, the Ombudsman has made several recommendations, including:

• Issuing an apology to Ms D.
• Reviewing care planning practices to ensure comprehensive and person-centred care.
• Implementing appropriate pain assessment tools for patients with learning disabilities.
• Conducting regular audits of nursing documentation, including care plans and seizure charts.
• Providing staff training on mental capacity and best interest decision-making.
• Collaborating with local social services to ensure safe staffing levels for vulnerable patients.

The Health Board has accepted these findings and agreed to implement the recommended actions to prevent such failures in the future.