Mrs C complained about the care and treatment her late mother, Mrs B, received from Cwm Taf Morgannwg University Health Board (‘the Health Board’) when she was admitted to Prince Charles Hospital between 22 and 26 April 2024. The investigation considered Mrs C’s complaint that Mrs B did not receive a reasonable standard of care including insufficient monitoring and medication for pain and agitation, delays in medical assessment and referral to a suitable ward for end-of-life care. The investigation also considered Mrs C’s complaints that Mrs B was supported to orally eat and drink when it was unsafe, and she required an assessment by the Speech and Language Team (‘SALT’), and that the Health Board’s complaint response was compromised by factual inaccuracies.
The investigation found that there were failings in the care provided to Mrs B including in relation to monitoring Mrs B’s pain, and delays in using a syringe driver (a device used to deliver medication under the skin), administering medication and in referring Mrs B to an appropriate ward. These complaints were upheld.
While it was found that the referral to the SALT was not actioned, it was found that this did not cause any harm to Mrs B and this complaint was not upheld.
Finally, failures were identified in the handling of Mrs C’s complaint and this was upheld.
The Health Board agreed to apologise to Mrs C for the failings identified. It also agreed to share the findings of the investigation with relevant staff and remind staff to use appropriate pain assessment stools, to complete accurate record keeping, and ensure timely actions are taken following medical reviews. It also agreed to review its handling of Mrs C’s complaint.