Mrs L complained about the care and treatment her late mother, Mrs K, received from the Health Board between January 2021 and her death on 31 January 2022 from biliary sepsis (a serious infection of the bile ducts). In particular whether monthly blood tests were an appropriate way to monitor her condition from January 2021, and the follow-up care for Mrs K following a biliary stent in November 2021.
Mrs K had pancreatitis (inflammation of the pancreas) in January 2021. An ultrasound scan was undertaken but the Ombudsman found that the scan was inadequate as Mrs K’s bile duct was not visible, so it could not be seen whether gallstones were present. The Ombudsman found that given Mrs K’s clinical history the most likely cause for pancreatitis was gallstones, but the Health Board had concluded it was steroid induced pancreatitis despite the scan being unclear. The failure to identify Mrs K’s gallstones in January 2021 meant her condition remained untreated.
In August, Mrs K developed other symptoms. Scans undertaken in the autumn showed evidence of a blocked bile duct which required surgery in November. The Ombudsman found that she should have been treated sooner and these were further missed opportunities by the Health Board to identify the seriousness of Mrs K’s condition.
The surgery did not fully resolve Mrs K’s condition, and she sadly died in January 2022.
The Ombudsman concluded that if Mrs K had been treated appropriately at the outset, her pancreatitis would have been treated successfully and her deterioration and death may have been prevented. This was a grave injustice to Mrs K and her family.
The Ombudsman also found little to no evidence that the seriousness of Mrs K’s condition was appropriately communicated in October to her and her family either before or after treatment.
Public Services Ombudsman for Wales: Investigation Report The Ombudsman found that although the surgery in November was carried out too late for Mrs K, the procedure was performed to the required standard. A further procedure was scheduled for 8 weeks’ time, and this was a reasonable amount of time for Mrs K to wait.
The Ombudsman was concerned at the Health Board’s seeming lack of candour in its complaint response to Mrs L, and its lack of objective reflection by its clinicians during the Ombudsman’s investigation in that it continued to fail to identify and acknowledge failings in Mrs K’s care.
The Ombudsman made a number of recommendations, which the Health Board accepted. These included to: • Provide Mrs L with a full apology from the Chief Executive for the failings identified in this report.
• Pay Mrs L £4,000 financial redress reflecting the serious failings found and the resulting and lasting significant impact upon her and her family.
• Review this case, in line with its legal requirements under the Duty of Candour, to determine how Mrs K’s presentation in January 2021 was misdiagnosed owing to inadequate assessment/imaging. The Health Board to report its findings to its Quality and Patient Safety Committee and in its Annual Report on the Duty of Candour.
• Share the Ombudsman’s report with the Clinical Director responsible for the consultants involved in Mrs K’s care so that its findings are reflected upon and discussed with those consultants.
• Review its handling of Mrs L’s complaint in line with the Duty of Candour.