Mrs C complained about the care and treatment provided to her late mother, Mrs A, during her admission to the Emergency Department (“ED”) of Ysbyty Glan Clwyd (“the Hospital”) between 21 and 24 January 2023. In particular, the investigation considered whether there was a delay in the provision of a bed, antibiotics, pain relief and a delay in clinical review.
The investigation found that the care and treatment provided to Mrs A during her admission to the ED between 21 and 24 January 2023 fell below an appropriate level. It was found that there was a delay in provision of a bed for Mrs A, in administering antibiotics and pain relief and in carrying out a clinical review. The Ombudsman found that the significant deficiency in this case was the failure to escalate the surgical team’s non-response to a more senior clinician. This failing meant that Mrs A did not get timely clinical intervention. Had this occurred, in all likelihood, this could have led to clinical intervention sooner and with a more senior surgical review. Had this happened it is likely that the severity of her illness and the need for antibiotics would have been recognised sooner. It is possible, although not certain, that if Mrs A had received earlier antibiotics, her outcome might have been different. The delay in administrating pain relief would have caused Mrs A additional distress. The Ombudsman considered that the failings in this case were fundamental, went to the heart of good clinical care, and to that extent, were unacceptable. The service failings identified, caused a significant injustice to Mrs A and her family and they will always have to live with the knowledge that opportunities were missed in their mother’s care and management. The Ombudsman therefore upheld the complaint.
The Ombudsman made a number of recommendations, which were accepted by the Health Board. These included apologising to Mrs C and family for the failings identified by the investigation as well as developing protocols for internal communications and escalation. As part of quality assurance, the Health Board will share this report with its Quality and Patient Safety Committee and to consider the investigation findings in relation to the Health Board’s Duty of Candour and include it in its Annual Report on the Duty of Candour.