Dr C complained about the care and treatment her late mother, Mrs A, received from Hywel Dda University Health Board on 28 and 29 December 2022 when she was an inpatient at Withybush Hospital (“the Hospital”). The following matters were investigated: a) Whether Mrs A’s pain relief was appropriate and adequately monitored.
b) Whether the provision and monitoring of fluids for was adequate.
The Ombudsman’s investigation found that the appropriateness of pain relief, and the justification for the approach taken in regard to Mrs A’s fluid management were not adequately documented. Given this failure, it was not possible to definitively conclude that Mrs A was effectively managed. This uncertainty is a source of injustice for Dr C and her family. The complaint was upheld.
The Ombudsman recommended that the Health Board apologise to Dr C for the failing identified in the report, that it reviews documentation to definitively address the appropriateness of individual symptom control and improve patient experience, and it remind the Medical teams at the Hospital of the need to ensure there is clear documentation to explain and justify why a specific approach has been taken in relation to a patient’s care. The Health Board agreed to carry out these recommendations.