Mrs C complained about the care and treatment her late father, Mr A, received from Hywel Dda University Health Board. Specifically, the investigation considered whether there were any unnecessary delays in Mr A’s cancer treatment, whether a Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) form was completed against Mr A’s wishes and contrary to national guidance and whether the nursing care Mr A received at the end of his life fell below the required standard.
The investigation found that whilst there were unnecessary delays in Mr A’s cancer treatment, these delays would not have significantly affected or impacted the long-term outlook for Mr A. Although this complaint was not upheld, the Health Board was invited to consider the delays and how improvements could be made.
The investigation also found that the documentation regarding the DNACPR was incomplete, so it was difficult to ascertain if the decision regarding the DNACPR during Mr A’s final illness was made with his full knowledge and consent. This uncertainty was an injustice to Mrs C, and this part of the complaint was upheld.
In relation to the nursing care provided to Mr A at the end of his life, it was determined that this did not meet the required standard. Although the Health Board created an action plan to address the deficiencies identified when it responded to Mrs C’s complaint, there was no learning or commitment from the Health Board around preparing patients with progressive or terminal illnesses, and their relatives, for death. Therefore, this part of the complaint was upheld.
The Ombudsman recommended that Mrs C should receive an apology for the failings identified. In addition, it was recommended that the Health Board carry out a number of tasks including sharing the report with nursing staff involved in Mr A’s care, reminding staff of national guidance and to carry out an audit of DNACPR conversations to ensure they fulfilled national guidance.