Clinical treatment outside hospital; GP : A GP Practice in the area of Cwm Taf Morgannwg University Health Board Report Date 16/02/2024 Case Against Cwm Taf Morgannwg University Health Board Subject Clinical treatment outside hospital; GP Case Reference Number 202301750 Outcome Upheld in whole or in part Mr B complained that the Practice failed to provide appropriate care and treatment to his mother, Mrs B, shortly before she sadly died. Mr B complained that the Practice failed to call an ambulance or inform his sister, Mrs A, that their mother needed to be admitted to hospital. Mr B was concerned that this had an impact on Mrs B’s subsequent treatment and/or outcome. Mr B complained that the Practice failed to provide an accurate complaint response.
The investigation found that the assessment and clinical decisions about the care of Mrs B were reasonable. There was no evidence of any failure in the care and treatment provided to Mrs B. This part of the complaint was not upheld. The investigation identified that the Practice had agreed Mrs A could attend the home visit to provide support during the medical assessment but failed to inform the GP undertaking the home visit. Consequently, Mrs A was not notified about the home visit. This part of the complaint was upheld. However, whilst the Practice had already acknowledged its failing, apologised, and explained what action it had taken as a result, there was no unremedied injustice for Mr B. The Practice was however asked to reflect upon the issue. Although the Practice failed to call an ambulance and notify Mrs A that her mother needed to be admitted to hospital, there was no evidence that this clinically impacted the outcome for Mrs B. This part of the complaint was not upheld. The investigation identified shortcomings with record keeping concerning whether the Practice had called an ambulance or not. Therefore, this impacted the Practice’s ability to provide an accurate complaint response. This part of the complaint was upheld.
The Ombudsman obtained the Practice’s agreement to implement the following recommendations: 1. To implement recommendations made during the Health Board’s investigation regarding procedural and/or process aspects around calling an ambulance, home visits and record keeping.
2. Within 15 working days of implementing all of the Health Board’s recommendations, issue a letter to Mr B confirming completion.
3. Within 15 working days issue a written apology to Mr B in recognition of the stress and inconvenience resulting from the failure to provide an accurate complaint response.