FOR INFORMATION AGENDA ITEM 4.2 18 September 212 PUBLIC SERVICES OMBUDSMAN WALES (PSOW) ANNUAL LETTER 211/12 Report of: Executive Nurse Director Paper prepared by: Assistant Director of Patient Safety & Quality Executive Summary Following the publication of the Public Services Ombudsman for Wales (PSOW) Annual Report, an organisational letter has been issued to the UHB which provides a clear and concise breakdown of all complaints relating to the UHB, received and investigated by the Ombudsman during 211/12. The letter which is attached outlines time taken in responding to requests for information, as well as summaries of all reports issued. Health complaints continue to be the most numerous types of complaint and account for almost a third of all complaints received. There was also an overall increase in the number of complaints taken into investigation by the PSOW (13% increase on 21/11). Whilst this trend will have been influenced by the NHS Redress Measure which came into force on 1 April 211, the PSOW is of the view that people are increasingly inclined to complain about poor service in the NHS. In relation to responding to PSOW requests for information, the UHB has raised concern with the PSOW office, as whilst performance is better than most Health Boards in Wales, many of the UHB responses whilst in excess of 4 weeks were within the timescale set by the PSOW in their letter requesting information. Public Services Ombudsman Wales Page 1 of 4 Quality and Safety Committee Annual Letter 211/12 18 September 212
FOR INFORMATION A greater than average number of cases were resolved using Quick Fixes and Voluntary Settlements. However, it should also be noted that the number of Upheld reports also exceeds the figure which could be expected for the Health Board. The UHB continue to respond positively to the work of the PSOW, with an increased focus on related learning to address recurring trends. This report is being shared with Board of Directors, in order that Divisional Directors ensure that clinical staff recognise the importance of the PSOW s work and the relevance of their engagement in the concerns management process to help resolve concerns raised by patients and or their carers. The work associated with this letter is considered routinely by the Concerns/Claims Review Group which is chaired by the UHB Chair. Related issues will also be discussed when the Chair and the Executive Nurse Director meet with the Ombudsman in September. The Quality and Safety Committee is requested to: Note the Public Services Ombudsman Wales (PSOW) Annual Letter for 211/12. The report has financial consequences: No Board Assurance Framework: The Report provides assurances against Healthcare Standard 23 Dealing with concerns and managing incidents and mitigates against risks identified with the Patient Safety (2) and Patient Experience (4) domains of the Board Assurance Framework. Public Services Ombudsman Wales Page 2 of 4 Quality and Safety Committee Annual Letter 211/12 18 September 212
FOR INFORMATION INTRODUCTION PUBLIC SERVICES OMBUDSMAN WALES (PSOW) ANNUAL LETTER 211/12 The Public Services Ombudsman for Wales (PSOW) aligned with publication of his Annual Report, also issues an organisational Annual Letter for 211/212. The Annual letter to the Accountable officer outlines PSOW related activity of concerns emanating in this Health Board which have been referred to his office for independent review. Since the introduction of Putting Things Right / NHS Redress (April 211), the second stage independent review process was removed, with independent review of concerns being directed to the Ombudsman s office. Prior to April 211, there was an NHS Independent Review process, prior to escalation to the Ombudsman. PSOW LETTER Attached as Appendix 1, is the PSOW Annual letter to the Chief Executive and is also available via the PSOW web site on the attached link; http://www.ombudsman-wales.org.uk/en/public-body-information/annual- letters/~/media/files/annual%2letters%2211-212%2- %2English/211-212%2Cardiff%2and%2Vale%2appendix.ashx The letter outlines time taken in responding to requests for information, as well as summaries of all reports issued. Health complaints continue to be the most numerous types of complaint and account for almost a third of all complaints received by the PSOW. There was also an overall increase in the number of complaints taken into investigation by the PSOW (13% increase on 21/11). Whilst this trend will have been influenced by the NHS Redress Measure which came into force on 1 April 211, the PSOW is of the view that people are increasingly inclined to complain about poor service in the NHS. In relation to responding to PSOW requests for information, the UHB has raised concern with the PSOW office, as whilst performance is better than most Health Boards in Wales, many of the UHB responses whilst in Public Services Ombudsman Wales Page 3 of 4 Quality and Safety Committee Annual Letter 211/12 18 September 212
FOR INFORMATION excess of 4 weeks were within the timescale set by the PSOW in their letter requesting information. A greater than average number of cases were resolved using Quick Fixes and Voluntary Settlements. However, it should also be noted that the number of Upheld reports also exceeds the figure which could be expected for the Health Board. LEARNING AND IMPROVING OUTCOMES FOR PATIENTS Each of the cases investigated and upheld by the Ombudsman is considered by the UHB and any actions for improvement are taken and outlined within the letter of apology to the complainant and if appropriate, a copy of the relevant action plan is also included. Other than the general trend of clinical treatment in hospital which represents greater than 2/3 rd of all complaints directed to the Ombudsman s office, there is no specific trend within the UHB. However, a theme relating to the time it has taken to respond to concerns, is apparent within a number of cases referred to and investigated by the Ombudsman. CONCLUSION The UHB continue to respond positively to the work of the PSOW, with an increased focus on related learning to address recurring trends. This report is being shared with Board of Directors, in order that Divisional Directors ensure that clinical staff recognise the importance of the PSOW work and the relevance of their engagement in the concerns management process to help resolve concerns raised by patients and or their carers. The work associated with this letter is considered routinely by the Concerns/Claims Review Group which is chaired by the UHB Chair. Related issues will also be discussed when the Chair and the Executive Nurse Director meet with the Ombudsman in September. RECOMMENDATION The Quality and Safety Committee is asked to: NOTE the Report Public Services Ombudsman Wales Page 4 of 4 Quality and Safety Committee Annual Letter 211/12 18 September 212
Our ref: PT/jm Ask for: James Merrifield Your ref: 1656 644 2 Date: 13 July 212 James.Merrifield@ombudsman-wales.org.uk Mr Adam Cairns Chief Executive Cardiff and Vale University LHB Cardigan House University Hospital of Wales Heath Park Cardiff CF14 4XW Dear Mr Cairns Annual Letter 211/12 Following the recent publication of my Annual Report, I am pleased to enclose the Annual Letter (211/12) for Cardiff and Vale University Health Board. The Annual Letter provides you with a clear and concise breakdown of all complaints received and investigated by my office during 211/12 in relation to your Health Board. You will also find details of the time taken by your Health Board in responding to requests for information from my office, as well as summaries of all reports issued in relation to your Health Board. As outlined in my Annual Report, the total number of maladministration and service failure complaints received by my office increased by 13% compared with 21/11. Health complaints continue to be the most numerous type of complaint and account for almost a third of all complaints received. There was also an overall increase in the number of complaints taken into investigation by my office. Whilst this trend will have been influenced by the NHS Redress Measure which came into force on 1 April 211, I also believe that people are increasingly inclined to complain about poor service in the NHS. It is pleasing to note the increased levels of Quick Fixes and Voluntary Settlements which would not be possible without the cooperation of public bodies. This means that it has been possible to increase the number of complaints closed at earlier stages without the need for a full investigation (where it is clear that there are no systemic issues associated with the complaint). Nevertheless, my office has had reason to issue a number of Public Interest Reports during 211/12 which raised serious concerns and failings. Many of these relate to health complaints, and I would encourage all health boards to
revisit these reports, which are available on my website, to ensure that the lessons are learnt. The other public interest reports could also have general learning opportunities for health bodies. I raised concerns in last year s Annual Letters regarding the amount of time taken by public bodies in Wales in responding to requests for information from my office and it is disappointing that this situation has not improved. The statistics for 211/12 show that average response times for health bodies, as well as other bodies, in Wales has worsened to the extent that roughly three quarters of responses are received more than four weeks after they were requested. I continue to urge all Welsh public bodies to assist my staff in progressing their investigations by providing responses in a timely manner, and the figures indicate that there is scope for your Health Board to improve in this area. In reference to the performance of your Health Board, there has been a clear increase in the number of complaints received by my office, which has led to a slight increase in the number of complaints taken into investigation. Both of these figures are greater than the number of complaints which could be expected for your Health Board. As with the figures for 21/11, the majority of complaints continue to relate to Clinical treatment in hospital. In reference to the outcomes of complaints relating to your Health Board, it is pleasing to note that my office was able to close a greater than average number using Quick Fixes and Voluntary Settlements. However, it should also be noted that the number of Upheld reports also exceeds the figure which could be expected for your Health Board. I have copied this correspondence to the Chair of your Health Board with the intention that it be considered by the Board. Finally, a copy of this letter will also be published on our website. Yours sincerely Peter Tyndall Ombudsman Copy: Chair, Cardiff and Vale University Health Board
Appendix Explanatory Notes Sections A and B provide a breakdown of the number of complaints against Cardiff and Vale UHB which were received and taken into investigation by my office during 211-212. Section C compares the number of complaints against Cardiff and Vale UHB which were received by my office during 211-212, with the average for health bodies during this period. The figures are broken down into subject categories. Sections D and E compare the number of complaints against Cardiff and Vale UHB which were received and taken into investigation by my office in 211-212, with the average for health bodies (adjusted for population distribution 1 ) during the same period. Section F compares the complaint outcomes for Cardiff and Vale UHB during 211-212, with the average outcome for health bodies during the same period. Public Interest reports issued under section 16 of the Public Services Ombudsman (Wales) Act 25 are recorded as Section 16. Section G compares Cardiff and Vale UHB s response times during 211-212, with the average response times for health bodies, and the average for all public bodies in Wales during the same period. Graph G measures the time between the date my office issues an investigation commencement letter, and the date my office receives a full response to that letter from the public body. Finally, Section H contains the summaries of all reports issued in relation to Cardiff and Vale UHB during 211-212. In order to assist in measuring performance during 211-212, sections A-G also contain the relevant figures for 21-211, adjusted for population distribution. 1 http://www.wales.nhs.uk/sitesplus/922/home
A: Complaints received by my office Subject 211-212 21-211 Appointments/ Admissions/ Discharge and transfer procedures 3 8 Clinical treatment in hospital 4 21 Clinical treatment outside hospital 7 4 Continuing care 2 6 Medical records/ standards of recordkeeping 1 2 Non-medical services 1 1 Services for vulnerable adults 1 Patient list issues 2 Complaint-handling 2 Other 1 13 TOTAL 69 55 B: Complaints taken into investigation by my office 211-212 21-211 Number of complaints taken into investigation 22 2
No. of complaints No. of complaints C: Comparison of complaints by subject category with average for health bodies 211-212 5 4 4 35 Cardiff and Vale UHB Health body average 3 2 1 3 3 Appointments / admissions / discharge & transfer procedures Clinical treatment in hospital 7 3 Clinical treatment outside hospital 6 2 1 1 1 1 1 2 1 2 1 Continuing care Medical records / standards of record-keeping Subject category Non-medical services Services for vulnerable adults Patient list issues Complaint handling 1 8 Other 21-211 3 2 21 2 Cardiff and Vale UHB Health body average 13 1 8 4 Appointments/ admissions/ discharge and transfer procedures Clinical treatment in hospital 4 3 Clinical treatment outside hospital 6 6 Continuing care Subject category 2 1 1 Medical records/ standards of recordkeeping Non-medical services Other 5
No. of complaints No. of complaints D: Comparison of complaints received by my office with average for health bodies 1 Cardiff & Vale UHB Health body average 75 69 64 55 5 41 25 211-212 21-211 Complaints received E: Comparison of complaints taken into investigation by my office with average for health bodies 5 Cardiff & Vale UHB Health body average 4 3 2 22 21 2 14 1 211-212 21-211 Complaints investigated
No. of outcomes No. of outcomes F: Comparison of complaint outcomes with average outcomes for health bodies, adjusted for population distribution 211-212 3 2 1 1 2 Out of jurisdiction 21 18 Premature 13 14 'Other' cases closed after initial consideration 1 Discontinued 1 9 Quick fix/ Voluntary settlement Complaint outcome Cardiff and Vale UHB 1 12 Section 16 - Other Report - Upheld - in whole Upheld - in whole or in part or in part 7 Health body average 6 5 Other Report - Not Upheld 1 1 Withdrawn 21-211 2 1 2 2 Out of jurisdiction 15 12 Premature 13 9 Investigation not merited 6 3 3 Quick fix/ Voluntary settlement 1 Discontinued Section 21 - upheld Complaint outcome 8 Cardiff and Vale UHB 7 11 6 Section 21 - partially upheld Health body average 5 4 Section 21 - not upheld 3 1 Section 16 - upheld
% of responses G: Comparison of Cardiff and Vale UHB s times for responding to requests for information with average for health bodies and All Wales response times, 211-212 1 Cardiff and Vale UHB 8 Average HB response time 6 Average All Wales response time 57 4 33 33 31 3 3 2 18 15 14 14 5 7 5 2 2 2 3 2 <1 week 1 to 2 weeks 2 to 3 weeks 3 to 4 weeks 4 to 5 weeks 5 to 6 weeks Over 6 weeks Response time
H: Report summaries Other reports - Upheld March 212 Clinical treatment in hospital Cardiff and Vale University Health Board Mrs A complained about the Surgeon s lack of experience in carrying out a surgical procedure to treat her haemorrhoids. She said that during the procedure he had telephoned a friend for advice and had failed to inform her that this was the first time he had carried out the haemorrhoidal artery ligation procedure. Mrs A also complained about the Health Board s five months delay in responding to her complaint. The Ombudsman s investigation concluded that whilst the Surgeon had relevant experience and expertise to carry out the procedure he had failed to follow guidelines the Health Board had in place when undertaking any new procedures. In relation to the Health Board s delay in responding to Mrs A s complaint the Ombudsman concluded that a delay of five months to address Mrs A s concerns was excessive and amounted to a service failing. Mrs A s complaint was upheld. Amongst the recommendations the Ombudsman made were that the Health Board should provide Mrs A with a fulsome apology for the failings identified in her care and make a redress payment of 25. He also recommended that the shortcomings identified in the report should, as a part of a wider learning exercise, be discussed at an appropriate consultant s forum. Case reference 21134 February 212 Clinical treatment in hospital Cardiff and Vale University Health Board Miss E complained that both the Dental Hospital and the GP Practice had failed to refer her late father, Mr E, for further investigations in a timely manner. When he was referred, he was diagnosed with oral cancer and sadly died soon after. The Ombudsman sought clinical advice on the complaint. The GP complaint: The Ombudsman found shortcomings in the standard of record keeping and also that a hospital referral was not made as planned. The adviser felt that there were sufficient factors to raise the level of suspicion in this case, though, having taken account of the relevant guidance, he was not able to pinpoint an exact date at which a referral should definitely have been made, given the lack of specific detail in the GP notes. The Ombudsman therefore partly upheld this complaint. The Dental Hospital complaint: The clinical advice indicated that whilst the initial diagnosis reached had been reasonable, a referral should have been triggered at the follow-up appointment when the Consultant recognised that the nature of the pain was not consistent with the initial diagnosis. In addition, there had been a delay in arranging the follow-up appointment. The Ombudsman partly upheld this complaint. It was acknowledged that the eventual sad outcome would not have been different.
However, in relation to both the GP and Dental Hospital complaints, the advisers stressed the importance of taking account of both current and past tobacco and alcohol use in considering cases where there were suspicious oral symptoms. Both current and past uses are significant risk factors for oral cancer. Case references 211325 & 2111142 January 212 Clinical treatment in hospital Cardiff and Vale University Health Board Mr Y complains about delay by the Health Board in recognising the recurrence of his wife s illness shortly before her death. Mrs Y was diagnosed in 27 with multiple myeloma and suffered complications with renal failure. He was also unhappy about her medical and nursing care following her admission to hospital in January 29. The Ombudsman found that there should have been closer monitoring and more heightened clinical awareness of Mrs Y s vulnerability and signs that the disease was progressing. A number of signs of Mrs Y s deterioration should have alerted clinicians but opportunities to carry out further tests or to assess her condition were missed. In particular an abnormally high test result was missed. Mrs Y was admitted to hospital in 29 with renal failure and improved initially after treatment. Although she did not require dialysis she still had significant renal failure which needed appropriate management. The Ombudsman found that there was insufficient consultation with renal specialists following Mrs A s move to a haematology ward. On the nursing side, the care was less than reasonable in the administration of medicine, nutrition (poor documentation of intake) and pain assessment. There were also complaint-handling delays. The Health Board agreed to make a number of changes in response to the shortcomings identified. It also agreed to make Mr Y a payment of 25 for his time and trouble in making the complaint. Case reference 21269 January 212 Clinical treatment in hospital Cardiff and Vale University Health Board Mr A s and Ms A s complaints concerned the care provided for Mrs B, Mr A s late sister and Ms A s late mother. They complained about the way in which Swansea NHS Trust ( the First Trust ) and Cardiff and Vale NHS Trust ( the Second Trust ) managed Mrs B s blood stem cell transplant ( the transplant ). They expressed concern about Mrs B s pre-transplant assessment, her treatment plan and her consent to treatment. They contended that Mrs B s pre-transplant assessment was inadequate and that this compromised her treatment plan and her ability to give informed consent to it. The Ombudsman partly upheld the pre-transplant assessment aspect of Mr A s and Ms A s complaint, against the Second Trust, because he considered that it should have ensured that a CT scan, in respect of Mrs B, was completed shortly before her transplant. He also partly upheld the consent element of their complaint, against the Second Trust, because he was of the view that the absence of an up-to-date CT scan adversely affected Mrs B s capacity to give informed consent to her transplant. He did not uphold the pre-transplant assessment or consent aspects of Mr A s and Ms A s complaint, against the First Trust, because he considered that the Second Trust, as the Trust undertaking the transplant, was responsible for these matters. He
did not uphold the treatment plan part of Mr A s and Ms A s complaint against either the First Trust or the Second Trust. The Ombudsman recommended that Cardiff and Vale University Health Board should acknowledge, in writing to Mr A and Ms A, that the Second Trust s completion of a CT scan, shortly before the transplant, would have promoted Mrs B s ability to give informed consent to it. He asked it to apologise to Mr A and Ms A for the Second Trust s failure to complete such a scan and to recognise this failing. He recommended that it should prepare and use a pre-transplant investigation checklist. He asked it to give copies of the patient transplant counselling checklists to the transplant patients concerned. He recommended that it should revisit the issue of informed consent if the period between the original pre-transplant counselling session and the anticipated transplant date exceeds eight weeks. He asked it to ensure that this report is shared with relevant clinicians and that the issues that it raises are discussed in an appropriate forum. Cardiff and Vale University Health Board agreed to comply with all of these recommendations. Case reference 21261 December 211 Clinical treatment in hospital Cardiff and Vale University Health Board Mrs A s main complaint was that she was in much more pain since a procedure to remove varicose veins had been performed. She also complained that the procedure carried out differed from what she had been told would happen. In particular, although the varicose veins in her legs had been removed, the vulval varices (varicose veins in the groin area) had not. Mrs A felt that the failure to do this was a contributory factor in her increased pain. Clinical advice was sought from the Ombudsman s clinical adviser. On the basis of the evidence considered, the Ombudsman concluded that whilst it could not be discounted that a small element of Mrs A s post operative pain might be due to the presence of vulval varices, a much more likely cause of Mrs A s pain was damage to the nerves which can sometimes occur as a result of surgery. The Ombudsman s investigation also found that communication within the Health Board was not as effective as it should have been. This was compounded by inadequacies in clinical record keeping and the way that the Health Board dealt with Mrs A s complaints. The Ombudsman recommended that the Health Board should: offer Mrs A redress of 25 in recognition of the inadequacies in the Health Board s complaints handling which had caused uncertainty and inconvenience to her; and, detail the measures it intended to take to address the shortcomings identified in the report. It should then communicate the steps to be taken to both this office and the complainant. Case reference 211985
November 211 Other Cardiff and Vale University Local Health Board & Welsh Health Specialised Services Committee Ms A was diagnosed as having Gender Dysphoria. At the end of 26 Ms A "transitioned" and started to live and present herself as a woman. Ms A began hormone treatment as a private patient. Ms A also planned to have surgery carried out privately but by early 21 she opted for NHS funding for her treatment and surgery as this became an option and was more appropriate to her circumstances at that time. The local Consultant Psychiatrist made a funding application in April 21 for treatment for Ms A as required under the Gender Dysphoria Commissioning Policy operated by Welsh Health Specialised Services Committee (WHSSC). On 18 June 21 Ms A s application was considered by a Panel of Advisers to WHSSC who assess applications for appropriateness and robustness. Ms A s application was declined with a request for more information and a second opinion. On 9 September a further Panel decision was made and it was agreed to proceed with the application with a request for further information from Ms A s private doctor. Ms A did not consent to this request and an exceptional decision was then made by WHSSC on 16 September for onward referral. Ms A s complaint was against both Cardiff and Vale University Health Board and WHSSC. She complained that the refusal / delay in funding her treatment for gender dysphoria was not in line with the existing Commissioning Policy. The Ombudsman partially upheld this complaint as the Commissioning Policy was unclear but he considered that the WHSSC Panel were justified in requesting further information and this was provided for in the Policy. Ms A also complained that there had been a failure to correctly investigate her complaint about the administration of hormone treatment and Ms A referred to a lack of clarity in responsibility for prescribing hormone medication on the NHS pathway. Ms A had to pay privately for her hormone medication. The Ombudsman found that there was a failure to respond to Ms A s concern and request for a continuation of her hormone treatment on the NHS and Ms A was treated as if she was presenting for the first time. The Ombudsman upheld this aspect of the complaint. Ms A also complained about a staff member / team at WHSSC and she believed the complaint had not been addressed by WHSSC. The Ombudsman did not uphold this element as the complaint had in fact been investigated. WHSSC was however invited to review its complaints procedure to ensure that its role and responsibilities were clearly identified and communicated. The Ombudsman recommended that WHSSC and the Health Board apologise to Ms A for the distress caused by the ambiguity of the Commissioning Policy and for the failure to adequately address her hormone treatment. He also recommended that WHSSC reviewed and developed the Commissioning Policy for Gender Dysphoria so that it is fit for purpose. Finally he recommended that the Health Board / WHSSC provide a redress payment to Ms A for the relevant hormone treatment that she purchased privately during 21 and a payment of 35 for the time and effort incurred in making the complaint.
Case reference 211675 & 211974 October 211 Clinical treatment in hospital Cardiff and Vale University Health Board Mrs C complained about the care and treatment that she received as a patient at a gynaecology clinic in 29 and 21. Mrs C complained that the registrar and gynaecologist at the clinic failed to carry out a thorough examination, correctly diagnose the cause of her symptoms and recommend appropriate treatment. Mrs C also complained about the delay in receiving a second opinion on her condition and was concerned that this delay in commencing treatment impacted on the severity of her condition and increased the likelihood of future surgery. The Ombudsman partly upheld the complaint. Having sought clinical advice, the investigation found that the clinical assessment carried out was inadequate. However, there was no evidence that had a physical examination been undertaken, it would have lead to an earlier diagnosis of Mrs C s condition. Although the investigation found that there was an unreasonable delay in the referral for a second gynaecology opinion, the evidence confirmed that a correct diagnosis of Mrs C s symptoms had been made, that the treatments recommended were appropriate and that if the original treatment plan had been followed by Mrs C this might have resulted in the resolution of her symptoms. Case reference 21251 September 211 Continuing Care Cardiff and Vale University Health Board Mrs A implied that the Independent Review Panel ( the Panel ), which considered the eligibility of her mother, Mrs B, for continuing NHS health care, did not take its eligibility decision properly. She questioned the Panel s independence. She suggested that it did not pay sufficient regard to Mrs B s health needs. She said that it adopted an input-related, as opposed to a needs-related, approach. She suggested that it did not take the quantity of care that Mrs B received into account. The Ombudsman was not persuaded that the Panel s independence was compromised. However, he was concerned that the Panel report and associated decision letters did not demonstrate that the Panel took its eligibility decision properly. As a result, he partly upheld Mrs A s complaint. He recommended that the Health Board should arrange for a new Panel to consider Mrs B s eligibility for continuing NHS health care. He asked it to write to Mrs A to apologise for its failings and to confirm the new Panel arrangements. He recommended that it should ensure that detailed minutes of the new Panel hearing are taken. He asked it to ensure that the decision letter sent to Mrs A, following this hearing, addresses the failings identified. The Health Board agreed to comply with all of these recommendations. It also arranged for another Health Board to undertake the agreed independent review on its behalf. Case reference 21122 July 211 Clinical treatment in hospital Cardiff and Vale University Health Board The complaint was made by Mr A s family about the care and treatment that the late Mr A received following his admission on two occasions to University Hospital of Wales.
During his first admission Mr A was prescribed Metolazone as a diuretic agent. Mr A was discharged home from hospital on the day he started taking the medication and due to an error he was not monitored as planned. The Ombudsman found that the prescription and administration of Metolazone was not properly supervised and monitored and he upheld the family s complaint. Mr A s family also complained that Mr A s Warfarin medication had been ceased on his second admission and he had not been tested for Aspirin resistance. The Ombudsman did not uphold this element as it was not unreasonable for this action to have occurred in Mr A s circumstances. The investigation identified that there was a joint cardiology/nephrology strategy in place in respect of Mr A and the Ombudsman also did not uphold the complaint that Mr A received a lack of cardiac monitoring following his second discharge from hospital. Mr A s family also complained about the complaint handling by the Health Board. The Ombudsman upheld the complaint that there was a significant delay in responding to the complaint and found that the answers the Health Board provided to Mr A and his family could have been more accurate and complete. Mr A s family also complained about being told to take the complaint elsewhere. The Ombudsman considered that in addition to recommending referral on there were still some points of clarity and a confirmation of apology which could have been provided by the Health Board and to that extent the Ombudsman upheld the complaint. Finally, the Ombudsman upheld the complaint that the Health Board failed to respond to the request for information on what had been done to prevent a reoccurrence of the error in medication monitoring. The Ombudsman recommended that the Health Board apologise to Mr A s family in relation to the management of Metolazone and provide a redress payment of 5 for the additional distress caused. He recommended that the Health Board ensures it has procedures in place for the proper monitoring of such drugs. He also recommended that the Health Board confirms that it has processes in place to ensure complaints are dealt with in a satisfactory manner and recommended a redress payment of 25 be paid to Mr A s family in recognition of the time and trouble associated with pursuing the complaints. Case reference 2147 June 211 Clinical treatment outside hospital Cardiff and Vale University Health Board and GP in Health Board area Miss A, aged 4 and a smoker, has adult onset diabetes. On 5 August 29, she went to the former Trust s Accident and Emergency Department ( the A&E ), accompanied by her parents, complaining of pain in her left leg. She was examined by a Specialist Registrar who concluded that Miss A had vitamin B deficiency. Miss A was advised to see her GP the following day. Miss A saw a GP at the Practice on 6 August and he prescribed her a painkiller for pain management and arranged for Miss A to have blood tests. Miss A telephoned the GP on 7 August and told him that her leg was turning a funny colour and that she was still in pain. Miss A said that the GP told her to continue with the painkiller and exercise her leg. Miss A said that she suffers from an arterial disease and the
restricted blood supply causes an ischaemic leg (where the blood supply is compromised and in severe cases, without treatment, can lead to the loss of the limb). Miss A complained that she had to undergo an amputation of her leg above the knee as a result of poor care provided to her by both the Hospital and the GP. The Ombudsman s investigation concluded that Miss A s condition and her symptoms were not fully explored on 5 August by the Specialist Registrar in the A&E and her complaint was upheld. The Health Board was asked to apologise for this failing. In relation to the complaint against the GP, the Ombudsman concluded that his failure to record a telephone consultation with Miss A on 7 August was a breach of the standard of recording expected by the professional body that regulates doctors. He was also critical that the GP had failed to examine Miss A, or, at the very least, refer her to an A&E department given the symptoms that Miss A described to him. The Ombudsman concluded that the failure to respond to Miss A s descriptions of her symptoms meant that the GP was unable to make an informed decision on the management of her care. Miss A s complaint was upheld and the Ombudsman recommended that the GP pay Miss A the sum of 15 for the distress and the uncertainty of not knowing whether a prompt referral may have made a difference to her prognosis. Case reference 21275 & 21361 May 211 Clinical treatment in hospital Cardiff and Vale University Health Board (UHB) Mrs P complained about the post-operative care provided to her husband, Mr P, following surgery for bowel cancer. In particular, she complained about the standard of infection control measures employed and the antibiotic treatment he received. Mrs P also complained about the standard of dietetic input Mr P received whilst in hospital. Mr P sadly died in January 29. The Ombudsman found that the overall standard of care in respect of infection control and treatment was reasonable. However, the Ombudsman concluded that there was an abject failure to assess, react to and implement solutions for Mr P s dietary problems. The Ombudsman recommended that the Health Board should apologise to Mrs P for the failings identified in this report and should implement both audits and new procedures to address those failings. Case reference 21119 May 211 Appointments, admissions, appeals and discharge procedures Cardiff and Vale University Health Board In 27 Mr Y underwent an operation for the removal of bowel cancer. From September 28 onwards, Mr Y suffered a series of urinary tract infections. A cystoscopy in February 29 showed possible cancer spread into the urinary bladder. Mr Y was then referred urgently to see the Consultant who had performed the surgery in 27. Mrs Y complained that Mr Y had to endure a six week wait to be seen by the Consultant, despite his condition and medical history. Mrs Y considered
that the unreasonable delay in seeing the Consultant contributed to the overall delay in Mr Y s treatment which eventually led to him being too weak to undergo surgery. Sadly, he subsequently died. Mrs Y also complained about poor communication on the part of the LHB s staff. Having sought clinical advice from two of the Ombudsman s professional advisers, the investigation found that, in view of Mr Y s condition and medical history, a six week wait to see the Consultant following an urgent referral was not acceptable. It was impossible to say what clinical effect the delay had but it caused considerable distress to Mr Y and his family. The complaint was upheld. The Ombudsman recommended that the LHB apologise to Mrs Y for the delay and demonstrate to her the action it said it has since taken to ensure that such delays do not recur. With respect to the complaint about poor communication, the investigation found that the LHB had taken an unduly long time to provide the test results to Mr Y, and this caused additional uncertainty and distress to Mr Y and his family. There was otherwise insufficient evidence to conclude that communication on the part of the LHB s staff had been maladministratively poor. This complaint was therefore upheld in part. The Ombudsman recommended that the LHB apologise to Mrs Y for the time taken to provide the test results. The LHB agreed to implement the recommendations. Case reference 2115 Other reports - Not Upheld February 212 Clinical treatment in hospital Cardiff and Vale University Health Board Mrs W complained that she was unnecessarily prescribed an antibiotic, which she said reacted with other medication she was taking. She said that the reaction triggered a heart problem which caused her to collapse, hitting her head, resulting in a significant cut to her scalp and knocking her unconscious. Mrs W complained that she had been given conflicting reasons for her collapse by clinicians. The Ombudsman found that clinicians involved in her care could have been more cautious in their diagnosis of what caused her collapse and should have explained more clearly the ambiguities which prevented a definitive conclusion being reached. However, the Ombudsman found that there was limited and questionable evidence in support of her having suffered from a heart problem at all and, in any event, any irregularity was minimal and not sufficient to have caused her collapse. The Ombudsman found that the most likely cause for Mrs W s collapse was low blood pressure, which was wholly unrelated to either the antibiotic she was prescribed or any minimal heart irregularity which might have briefly been present. Case reference 211231 January 212 Other Cardiff and Vale University Health Board Mr G complained about how the UHB had dealt with his daughter Z (an adult) who was being seen by its mental health services. In particular, Mr G said that a complaint made by him (acting as Z s advocate) was brought up by a consultant during a clinical appointment with Z. It was suggested the complaint was being
pursued without Z s consent. Consequently, Z had been unnecessarily upset. A request by Mr G for her to see a different psychiatrist had, he complained, been unreasonably declined. The investigation found that whilst Z had signed the form authorising Mr G to act in the complaint, the boxes about the release of medical information were left blank and the signatory at the foot of the form was not that of Z. The form s signatory section lacked clarity. It was reasonable for the UHB to query it, given it was dealing with a vulnerable patient and Z had previously instructed it not to disclose details from her medical records to her parents. It had already apologised for any distress felt by Z, indicating there had been no intention to upset her, and the Ombudsman could not know what exactly had been said. The Ombudsman s adviser concluded that it was not unreasonable for the consultant to ask Z about the complaint, as long as that did not form the focus of what was otherwise a clinical consultation. It was the first opportunity of directly asking Z about it. He also felt that it was not unreasonable in the circumstances to decline to change consultant. Z had been seen by many clinicians. It was not felt to be in her best interests to change again. Appointments had continued to be offered, and she could still access her GP, so the UHB s actions were reasonable. The complaint was not upheld. Case reference 21174 October 211 Clinical treatment in hospital Cardiff and Vale University Health Board Mrs H complained on behalf of her son, Mr A, that when he attended the Emergency Department at the University Hospital of Wales, Cardiff, he was sent home after being assessed by a triage nurse. Mr A was admitted to hospital later the same day after being seen by an out of hours GP, and was subsequently diagnosed with severe ulcerative colitis. The Ombudsman found that it was reasonable for the triage nurse to have sent Mr A home as, although he was unwell, his symptoms were not such as to require an emergency admission. In addition, Mr A had a pre-arranged out of hours GP appointment later that afternoon, and it was reasonable in the circumstances for the triage nurse to have advised him to attend that appointment. The Ombudsman did not uphold Mrs H s complaint, but he did make some observations about the standard of the triage records, which the Health Board agreed to share with the triage nurse. Case reference 211212 August 211 Clinical treatment in hospital Cardiff and Vale University Health Board Mrs H complained that her third cycle of IVF had not been managed well by the IVF clinic of Cardiff and Vale University LHB. She said that given her responses to medication designed to stimulate ovulation during a previous cycle of IVF, she should have been given scans more frequently which may have resulted in her medication merely being reduced rather than stopped, a process known as coasting. She believed these factors had contributed to a low fertilisation rate in her third cycle and that the LHB should therefore fund a further cycle of IVF.
The complaint, together the medical records for Mrs H s treatment, were considered by the Ombudsman s specialist clinical adviser. The outcome was that the Ombudsman did not uphold the complaint as he was satisfied that the treatment Mrs H had received was reasonable and in line with current medical evidence. He did however note some shortcomings in record keeping which he brought to the attention of the LHB. Case reference 21242 May 211 Clinical treatment in hospital Cardiff and Vale University Health Board (UHB) Mr DE and his son, Mr TE, complained that Mrs E (Mr DE s wife and Mr TE s mother) was inappropriately sent home from A&E on 31 May 29. She suffered from Chronic Obstructive Pulmonary Disease (COPD obstruction to the airflow). She retunred to A&E the following day and was admitted to intensive care (ITU). She sadly died there in July 29. Mr DE and Mr TE also complained that a meeting to discuss the withdrawal of life support was brought forward from Monday 6 July to Sunday 5 July. This did not give the family a chance to come to terms with what was happening, and Mr TE was upset to find his mother fully conscious when he went in to see her for the last time. Having taken clinical advice from two independent clinicians, the Ombudsman did not uphold either complaint. He found that the decision to discharge Mrs E from A&E was soundly based after tests and examinations had been carried out. He further found that, while the family were understandably distressed about the events surrounding the withdrawal of life support from Mrs E, it had been reasonable to bring the meeting forward, and it was reasonable not to sedate Mrs E as that was not clinically necessary at that time. Case reference 21493 April 211 Clinical treatment in hospital Cardiff and Vale University Health Board Mr T complained that A & E staff at a hospital under the management of the LHB, asked him to leave the premises without offering treatment during an evening in 21. He said that staff were generally unsympathetic and over reacted to his behaviour, which he admitted involved shouting and swearing. He stated that he had a very severe headache that explained his presentation. Mr T added that staff did not help him and then made him leave with security staff after he lost it. Mr T added that the LHB s complaint response amounted to blackmail as it insisted that he was welcome to future services but only if he behaved properly. The Ombudsman found that there was no evidence that staff acted unreasonably or outside of LHB policy, despite the obvious distress that Mr T had experienced concerning the event. He also concluded that the complaint response letter was appropriate. The Ombudsman did not uphold Mr T s complaints. Case reference 211685