Ms X complained about the care her late father, Mr Y, received from Betsi Cadwaladr University Health Board at the Acute Medical Unit at Ysbyty Glan Clwyd (“the Hospital”) in June 2022. Her concerns included whether her father’s nutritional intake was managed appropriately, including the referral to the Speech and Language Team (“SALT”). Whether his pain was managed appropriately, including the referral to Palliative Care and if his risk of falls was managed appropriately. Finally, whether his management shortly before his collapse on 9 June 2022 was appropriate.
The Ombudsman’s investigation found that Mr Y’s nutritional needs were not met. The nutritional screening tool, which would have shown he was at high risk of malnutrition was not completed, no referral was made to a dietician and a SALT referral was not made until the day Mr Y died, a week after his admission. No record was kept of his nutritional intake, and on occasions he was not offered prescribed nutritional supplements. The Ombudsman upheld this part of the complaint.
The Ombudsman found that on the whole Mr Y’s pain was managed appropriately, he was given frequent pain medication and there were no records of uncontrolled pain. A referral to Palliative Care was made promptly when it was decided that further treatment for his cancer was unlikely. This part of the complaint was not upheld .
The Ombudsman found that the falls risk assessment was not accurately completed; it did not identify risk factors and therefore Mr Y’s risk of falls was not managed appropriately. This part of the complaint was upheld.
The Ombudsman found that Mr Y’s care on 9 June was generally of a reasonable standard. He was reviewed by doctors when necessary, nursing staff attended to him many times in response to his requests to open his bowels, and regular routine checks were carried out. However, Mr Y was not given his prescribed laxatives the previous day, and this, indirectly, might have led to his apparent attempt to go the bathroom unaided. To this limited extent, this part of the complaint was upheld .
The ombudsman recommended that the Health Board remind staff on the AMU of the importance of accurately completing nutritional screening tools and falls risk assessments. Also carry out an audit of the completion of this documentation on the AMU. If this audit reveals significantly failings, the Health Board should arrange for refresher training for relevant members of staff within a further 3 month period.