The Public Services Ombudsman has upheld a complaint from a woman regarding the treatment her late father received at Aberystwyth's Bronglais Hospital in December 2008.
Mr Peter Tyndall branded Hywel Dda Health Board's investigation into the man's treatment as 'superficial', and said aspects of his care 'fell well below a reasonable standard'.
The woman ('Ms R') alleged that the hospital failed to record important information about the year 80-year-old man's diabetic regime and did not monitor his blood sugar properly.
She also said that there was evidence to suggest that nursing staff falsified the records of her father's ('Mr T') blood sugar monitoring to hide their failures.
During his stay in hospital, the man had suffered a hypoglycaemic attack, which Ms R claimed had led to a cardiac arrest. He died a few months later.
Ms R had said that her father - 'Mr T' - been admitted to hospital on the 22nd December 2008
In the early hours of the next day, he became hypoglycaemic, due to his blood sugar levels becoming too low. This caused him to vomit.
Mr T then suffered a cardiac arrest due to inhaling his vomit. As a consequence of this, he ended up needing 24 hr care. Soon after being discharged to a nursing home in 2009, he died.
The family complained about his care to the Hywel Dda Health Trust (now 'Health Board'). Dissatisfied with the Trust's response, they made their complaint to the Ombudsman.
Among their complaints were a lack of access to Mr T's medical records, staff shortages on the ward, and not giving him a bedtime snack to help boost his blood sugar levels.
Summing up his investigation, Mr Peter Tyndall concluded:
- Staff were not vigilant enough in recording information about Mr T’s diabetic regime.
- There was an inadequate response to the problem of short staffing on the Ward during 22/23 December 2008.
- Mr T’s blood sugar was not monitored properly.
- Other physiological measurements were not fully recorded.
- There appears to be a false blood sugar reading added retrospectively to the record.
- The response to the complaint was thin and protracted.
– Public Services Ombudsman for Wales
I think it is reasonable to say that the failings had a contributory effect on his deterioration and therefore, subsequent death.
My Medical Adviser has drawn that conclusion. I find his analysis measured and plausible.
I think it is fair to conclude that if Mr T had been given a bedtime snack and/or had his blood sugar checked at around 10.00pm on 22 December, there was a reasonable chance that he would not have had a cardiac arrest on 23 December.
None of this is certain. However, it is sufficient for me to say that poor care contributed to Mr T’s demise.
The Ombudsman recommended a written apology from the health board's Chief Executive, and that Ms R be paid £1700 for "additional distress" and to reflect the time spent pursuing the complaint.
He also called for an 'in-depth' review to be carried out into the skills and training of ward staff wards in monitoring the blood sugar levels of patients.
Hywel Dda Health Board, he wrote, has agreed to implement his recommendations.
Following the Ombudsman's report, the health board sent ITV Wales the following statement:
– Caroline Oakley, Director of Nursing and Midwifery
The care offered to this patient fell below the standards expected and I would therefore like to apologise to the family again on behalf of the Health Board. We fully accept the findings of the report and have undertaken immediate action to avoid such a situation from happening again.
"Since 2008, when this incident occurred, we have put in place numerous measures, including extra training for nurses in diabetes care and a review of the blood monitoring equipment.
"We are committed to on-going improvements, specifically for the growing number of patients living with chronic conditions, to ensure that we provide a patient-centred approach for every individual in our care."