Mr A complained about the care and treatment provided to him by Betsi Cadwaladr University Health Board’s (“the Health Board”) Glan Clwyd Hospital (“the Hospital”). Specifically, whether the care and treatment provided on 26 May 2022, including the decision to discharge him, was clinically appropriate. Mr A re-attended the Emergency Department (“ED”) the next day and was diagnosed with an infected gall bladder which was subsequently removed.
The Ombudsman’s investigation concluded that although Mr A did not have sepsis (a life-threatening reaction to an infection), discharge on 26 May was not appropriate. This was because a narrow focus of investigation was undertaken leading to a missed diagnosis and premature discharge from the Hospital. The injustice for Mr A was that, had a wider assessment and examination been carried out when Mr A initially attended the ED, it might have prevented his need to re-attend the following day following his discharge as well as lessened the time he was experiencing severe pain. The Ombudsman upheld the complaint.
The Ombudsman’s recommendations included the Health Board apologising to Mr A for the failings identified in the report, sharing the report with the treating team as a point of learning and providing record keeping reminders to clinicians about the need for detailed notes when assessing and examining a patient.