Mrs C complained about the care provided to her daughter, Ms A, by the Health Board. The investigation considered whether Ms A’s discharge from hospital on 21 November2022 was clinically appropriate.
The Ombudsman found that Ms A was discharged without a full assessment of her swallowing difficulties, following referral to the Speech and Language Therapy (“SALT”) team. It was not clear whether she could tolerate the oral antibiotic medications provided, and she was discharged without a fluid thickener prescription that may have made a difference to Ms A’s ability to tolerate that medication. There was also no apparent discharge co-ordinator or records to demonstrate whether Ms A had any further support needs prior to her discharge. While this may not have made a difference to the eventual outcome, this was an injustice to Ms A and her family. Ms A’s discharge was unacceptable, as the appropriate care and consideration was not given to her circumstances at that very challenging time. Therefore, the complaint was upheld.
The Ombudsman recommended that the Health Board apologise to Ms A’s family for the failures identified, and ensure that the Ombudsman’s report and its findings were shared with clinical staff, to enable staff reflection on the failing identified. She also recommended that the Health Board provide evidence to demonstrate its implementation of the improvements and actions it said had been taken, when it investigated Mrs C’s complaint.