Ombudsman criticises Aneurin Bevan Health Board and care watchdog over dementia patient's care

The Public Services Ombudsman has criticised Aneurin Bevan Health Board and the watchdog Care and Social Services Inspectorate Wales over the treatment of an elderly woman with Vascular Dementia who died in January 2010.

The Ombudsman was responding to a complaint from the woman's daughter, 'Ms A', over the standard of care provided at a specialist care home contracted by Aneurin Bevan Health Board.

He upheld a complaint against the health board, and partly upheld one against the CCSIW, for failings in the way it dealt with her daughter's complaints and investigated the treatment.

  • Records show the woman ('Mrs X') barely had more than one bath per month and was given meat when she was a vegetarian.
  • The report found there was no evidence of lessons being learned when she sustained injuries at the home
  • Mrs X's wish to die in her own bed, and not be admitted to hospital, was not met because of bad record-keeping.

With respect to Ms A's complaints about CSSIW, I found that the investigation process had been so narrow that serious failings had not been identified.

I also found that the CSSIW compliance process was not robust enough in this case to ensure that service user's basic needs were being adequately met.

Furthermore, despite CSSIW recognising that at the time of the investigation and publication of the investigation report, Ms A had not been satisfied with the findings and intended to pursue the matter further, it used the term “resolved” when describing her complaint, this was disingenuous.

I partly upheld this part of the Complaint.

– Peter Tyndall, Public Services Ombudsman for Wales

The Ombudsman advised that the health board and the CCSIW pay Ms A £500 and £250 respectively in recognition of the failures identified in the report.

As time goes on, more and more people will be cared for in nursing homes. We need to make sure that what happened in England - where the quality of care in homes wasn't being properly monitored - isn't repeated in Wales.

I know that the NHS in Wales are taking this seriously, but this is an issue that has to be dealt with across Wales, not just in this particular care home.

– Peter Tyndall, Public Services Ombudsman for Wales

The Chief Executive of Aneurin Bevan Health Board says the organisation is "committed" to following the Ombudsman's recommendations on improving care in its care homes.

Dr Andrew Goodall says he has met the Ombudsman to discuss the complaint made by 'Ms A'.

Aneurin Bevan Health Board accepts the findings of the Ombudsman and would wish to offer its sincere apologies to the family for the failings identified within the report.

The Health Board is aware that some of the matters in the report relate to a period up to and including October 2009, prior to the establishment of Aneurin Bevan Health Board.

Soon after its establishment, the Health Board recognised the issues covered in the report and has responded to these through changes to our Policies and Procedures and our general approach as an organisation.

– DR ANDREW GOODALL, CHIEF EXECUTIVE, ANEURIN BEVAN HEALTH BOARD