1. ITV Report

Missed diagnosis and delays before surgery were 'significant factors' in patient's death

The Ombudsman found that there had been many shortcomings in the patient's care at Glan Clwyd Hospital Photo: ITV News Wales

A missed diagnosis and a delay in carrying out surgery were 'significant factors' in the death of a patient at Glan Clwyd Hospital in Bodelwyddan, Denbighshire.

Wales' Public Services Ombudsman, Peter Tyndall, upheld a complaint against Betsi Cadwaladr University Health Board from the patient's daughter. The Health Board has agreed to a pay compensation for the trauma caused to the family, and has accepted the Ombudsman's recommendations to improve its procedures.

The patient died on 7 November 2009 following extensive surgery to drain a perianal abscess and treat the quickly-progressing and very serious infection which had developed. The Ombudsman noted that when he originally went to see his GP on 21 October 2009, he was well enough to travel by bus.

The Ombudsman's report highlighted:

  • A missed opportunity for review by a senior clinician (a consultant urologist) as an emergency admission
  • Test results not being recorded consistently throughout medical notes
  • Failure to act upon significant test results to review an initial diagnosis
  • Poor communication between medical staff
  • Poor communication with the patient's family - particularly as the patient had Alzheimer's disease and communication difficulties
  • No overall plan of nursing care for the patient
  • A 26-hour delay between when the patient's abscess was spotted and the operation being carried out was inappropriate, and was responsible for the extent of the surgery and the septic complications

Both the missed diagnosis and the delay in carrying out the surgery were significant factors in Mr Y's death. Proper investigation, a thorough review of the initial diagnosis and prompt treatment may well have led to [the patient's] survival. Also aspects of his nursing care fell below a reasonable standard and meant that the overall quality of his care was compromised. The consequences were devastating for [the patient], whose age and existing conditions made him vulnerable and less likely to survive such extensive surgery.

– Peter Tyndall, Public Services Ombudsman for Wales

The Ombudsman has recommended that the Health Board gives a meaningful apology to the patient's daughter, on behalf of his family, for the failings identified in his treatment, and makes a payment of £3,000 for the trauma caused to the family for the distressing way the patient died and the knowledge that the delays contributed to that.

His report also criticises Betsi Cadwaladr's delayed responses to earlier parts of the complaint process, which added to the family's distress. He acknowledges that the Health Board has introduced a number of general measures to improve the standard of care at Glan Clwyd Hospital since November 2009. He does make a number of recommendations for future procedure, including highlighting the importance of case notes and introducing a protocol to improve communication between medical staff. The Health Board has accepted the recommendations.

The Health Board has received the Ombudsman's Report and accepts its findings in full. Clearly in this instance, standards of care fell below the level patients and their families should expect us to provide. Addressing the issues in the Ombudsman's Report is now a priority for the Health Board and we have agreed a list of interventions which will build on the progress already made. These will include auditing clinical notes; reminding junior doctors of the importance of recording test results; improving communication between clinical teams and updating our training.

– Mr Mark Scriven, Executive Medical Director for the Betsi Cadwaladr University Health Board