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Patient dies after hospital fails to diagnose heart problem

Credit: PA

A report by the Public Services Ombudsman for Wales has revealed that a Hywel Dda Health Board patient suffered a cardiac arrest and died, after staff failed to correctly diagnose and manage his heart failure.

Mr F (anonymised) was admitted to the Prince Philip Hospital in Llanelli in May 2014 for a scheduled hip replacement operation.

This was carried out without complication and Mr F was recovering well.

A junior doctor reviewed Mr F the following day but he was not seen by a senior physician for the next three days, and two subsequent consultant visits weren't recorded.

Mr F was later deemed fit for discharge but when his family arrived to collect him, his condition had deteriorated.

Whilst a junior doctor diagnosed an intestinal blockage with possible sepsis, Mr F's additional condition of cardiac failure was never considered.

Mr F appeared to stabilise and his family returned home to allow him to rest. Shortly afterwards Mr F's blood pressure dropped alarmingly, and he suffered a fatal cardiac arrest.

Ms D contacted the Ombudsman to complain about her father's care after the Health Board failed to adequately respond to her concerns. The Ombudsman found that:

  • Despite Mr F's medical history putting him at risk of heart disease, no pre-operative ECG (Electrocardiogram - a test for problems with the heart's electrical activity) or chest x-ray were carried out
  • Due to lack of support, junior doctors failed to diagnose Mr F's cardiac condition which consequently led to an inappropriate care management plan
  • His family weren't informed of the seriousness of his condition, denying them the opportunity to be with him when he died
  • The Health Board failed to acknowledge the incomplete diagnosis and its implications.

It is extremely worrying that junior level staff were left unsupervised to make significant clinical decisions. The alarming lack of medical notes and failure to recognise Mr F's heart condition meant that opportunities to escalate him to the Medical Emergency Team were missed.

Not only did Mr F's family wait over 13 months for a response to their concerns which in itself is unacceptable, that response failed to acknowledge the incorrect provisional diagnosis and its dire implications.

This case demonstrates a catalogue of serious failings which, together, create significant doubt around whether Mr F's death was, as the Health Board suggested, inevitable.

– Nick Bennett, Public Services Ombudsman for Wales

Hywel Dda University Health Board said it has accepted the recommendations made by the Public Services Ombudsman for Wales.

Firstly we would like to express our genuine regret that on this occasion we did not provide the high standards of care that we aspire to.

We also acknowledge that the failings identified by the Ombudsman have caused additional distress and anxiety to the family and we wholeheartedly apologise for this.

We are a health board that is absolutely committed to learning from its mistakes to ensure we do not repeat them. Through our own internal investigation and the findings of the Ombudsman, we have put in place a robust set of measures to deliver the required improvements to prevent a situation like this from reoccurring.

We understand and appreciate that the publication of this report will be very upsetting for the family and we sincerely apologise for this.

We would also like to reassure our patients and the public of our determination to learn from this experience and to use the lessons we have learnt to provide the best possible care for our local communities.

– Dr Phil Kloer, Medical Director

The Health Board said as part of its plans it has:

  • Designed a system of regular ward audits to ensure thorough completion of observation charts, including recording all consultant contact with patients and medical assessments
  • Reassessed enhanced escalation protocols that support staff at all levels to assist with more effective communication and know who to approach at all times for advice and supervision
  • Developed a review of our complaints handling processes, including how we liaise with families, to ensure we acknowledge concerns raised with us in a timely way and offer people the opportunity to meet with us face to face as early on in the process as possible.