The investigation focused on Ms A’s complaint about the care and treatment she received when she attended the Emergency Department (“ED”) at Wrexham Maelor Hospital (“the Hospital”) on 26 November 2023. Specifically, the investigation considered: whether the diabetic ketoacidosis (“DKA”) Ms A experienced could have been prevented if she had been correctly triaged in the ED. The investigation also considered whether Ms A was appropriately treated on 27 November once the DKA was diagnosed.
The investigation found that without knowing Ms A’s blood glucose and ketones levels at the point of triage, it would be difficult to know for sure if she was already developing DKA when she presented to the ED. The shortcomings in Ms A’s care, meant that Ms A will be left with the uncertainty of not knowing whether her experience might have been prevented had she been properly triaged. This is an injustice to her. That said, if she was in DKA and had been correctly triaged, her treatment would have followed the standard DKA protocol and therefore, Ms A could still have ended up being admitted to the Intensive Therapy Unit. Given the identified failings and ensuing uncertainty, this aspect of her complaint was upheld to this limited extent.
The Ombudsman was broadly satisfied that once Ms A was diagnosed with DKA that she received appropriate treatment. However, the 6-hour delay was unacceptable, although this was due to difficulty in gaining IV access. This delay has caused Ms A and her family distress which was an injustice to her, and this aspect of the complaint was upheld. The Ombudsman recommended the Health Board provide Ms A with a written apology for the failings identified and provide evidence of the actions the Health Board said it has taken following Ms A’s complaint.