Mrs Y complained about the care and treatment her late mother, Mrs W, received from Cwm Taf Morgannwg Health Board. Mrs Y complained that informed consent was not appropriately obtained for an Endoscopic Retrograde Cholangiopancreatography procedure (“ERCP – an examination of the pancreatic and bile ducts using a thin tube with a light and camera on the end). Mrs Y complained that her mother did not receive appropriate post-operative care, including monitoring, pain relief and oral care. Mrs Y also complained that the decision making process for a Do Not Attempt Resuscitation decision (“DNACPR” – which informs clinicians that a patient is not to be resuscitated) was not undertaken appropriately.
My investigation found that the ERCP consent form was lost and it was not possible to determine if Mrs W had been provided with sufficient information to make an informed decision. This caused ongoing uncertainty to her family and this complaint was upheld. My investigation also found that Mrs W did not receive appropriate post ERCP observations, that the documentation of assessment of pain was below standard, and there were missed opportunities to ensure she received appropriate oral care. While these failings did not alter the outcome for Mrs W, this resulted in uncertainty about the timeliness of pain relief Mrs W received and this complaint was also upheld. Finally, my investigation found that the DNACPR decision was clinically reasonable and undertaken at the appropriate time. This complaint was not upheld.
I recommended that within 1 month of this report the Health Board should: a) Apologise to Mrs Y for the failings identified.
b) Remind relevant staff of the importance of record keeping and ensuring patient records are retained.
c) Remind relevant staff of the post ERCP procedure pathway monitoring requirements.
d) Remind staff of the “Adult Mouthcare Assessment”, “My Mouthcare Plan” and “Personal Care Monitoring Form”, and the need to re-assess a patient’s needs following a change in their condition.
I recommended that within 2 months of the date of the final report the Health Board should: e) Provide the Ombudsman with an update of the ward monthly pain assessment audits and action taken to address any issues identified.
f) Undertake an audit of the ward completion of the post ERCP procedure pathway monitoring and identify suitable actions to address any issues identified.
g) Bring this report, and the reasons I have issued it as a public interest report, to the attention of the Chair of the Quality and Safety Committee.
The Health Board was given a number of opportunities to comment on a draft of this report but it has not done so. The Health Board has therefore not confirmed if it accepts these recommendations and for that reason this report has had to be issued as a public interest report.