Aneurin Bevan Health Board and a care watchdog are criticised by the Ombudsman over the treatment of an elderly woman with dementia.
A missed diagnosis and delayed surgery were 'significant factors' in a patient's death at Glan Clwyd Hospital, according to the Ombudsman.
Mr Peter Tyndall upholds complaint from family of a man who was left brain damaged after suffering a hypoglycaemic attack in hospital.
The Public Services Ombudsman's report into the death of a dementia sufferer four months after he was admitted to a hospital in Swansea has found a 'pattern of failures.'
Abertawe Bro Morgannwg University Health Board has apologised and says major changes have taken place at Cefn Coed Hospital since then.
The Healthcare Inspectorate Wales says it's now considering strengthening its risk assessment and inspection process.
Here's our Health Reporter Rob Osborne.
– Healthcare Inspectorate Wales
I can confirm that the Ombudsman has forwarded his report to us and requested that we consider further action. We are currently considering our next steps as part of the work we are taking forward to strengthen and focus our risk assessment, inspection and follow-up processes in light of the Francis Inquiry report
'We've seen a number of cases where people at the end of their life have not been cared for properly," says Public Services Ombudsman Peter Tyndall.
"I think there are instances where cultural change will be called for. In many cases there is excellent care being provided, but there are still isolated cases of this kind that need to be tackled."
The distress of the family in losing a loved one is a matter of great concern. I think for them this is something that will always remain with them and it does again stress the importance you have to look after people at the end of their lives well.
"I am confident that the changes can be made and will be made, but I think it requires sustained management attention to make sure that we don't slip away from the standards that need to be sustained."
Abertawe Bro Morgannwg University Health Board says it "strives to continually improve" the care it offers vulnerable patients.
It says the ward in which Mr was treated has now been replaced by a purpose-built dementia unit, and that the hospital now has "better mechanisms in place to assess and serve patients' nutritional needs".
We would like once again to offer our most sincere condolences to the family of this patient for their sad loss; and to apologise for the shortcomings in important aspects of care this patient received, which we acknowledge fell well below the high standards expected.
We would like to give assurances that there have been major changes since the time this patient was an inpatient at Cefn Coed Hospital, particularly around pressure ulcer prevention.
– Abertawe Bro Morgannwg University Health Board
Pressure sores are not acceptable, and in almost all cases they are avoidable. Our clinicians have been determined to find ways to greatly reduce the risk of patients developing pressure ulcers, and in 2008 we began a major programme developing interventions to prevent pressure ulcers.
We successfully piloted this early work in 2009, in a small number of acute wards. They are now in use at all our hospitals, where nine wards have prevented patients developing any pressure ulcers for over three years; and a further seven wards have stopped pressure ulcers for over two years.
More needs to be done to care for elderly people in hospitals that are coming to the end of their lives, according to the Public Services Ombudsman for Wales.
It comes as a report is published today revealing 'a pattern of failures' in the care of a man with dementia who died four months after being admitted to Cefn Coed Hospital in Swansea.
Abertawe Bro Morgannwg University Health Board, which was criticised in the report, says it has overhauled some parts of its service since 2009 when the man died - and in the area of bed sore prevention it is now a world leader.
Here are some of the comments and experiences on nursing home care that you sent in via email, Facebook and Twitter:
I was employed as a senior in a private care home and have seen first-hand the poor conditions and care of the elderly with dementia.
Thank you for doing the news item on care for the elderly but unfortunately I don't think it will make a bit of difference. The system simply does not work.
Time and time again, we hear of failings in care, not just in elderly services but across the board, but implementation of changes is taking far too long.
My wife visits elderly people in their homes to assist them... The carers do at little as possible in the shortest time they can. They don't appear to care at all its just a job. It may be the company they work for is expecting them to do too much in too short a time. I also have a friend that is a carer and she is disgusted by some of her colleagues attitudes to their clients.
The Older People's Commissioner for Wales, Sarah Rochira, told ITV Wales that 'effective monitoring and regulation is crucially important in driving up the quality of care - but it's not in itself enough.' She calls for 'compassion, care, dignity and respect' to drive all care for old people.
The Public Services Ombudsman has severely criticised the people who are in charge of inspecting care homes across Wales and ensuring standards for some of our most vulnerable elderly people.
It follows a lengthy investigation into the case of an elderly woman who died three years ago. The watchdog says that the Care and Social Services Inspectorate's investigation was so narrow that 'serious failings had not been identified.'
Tonight Age Cymru is calling on the Welsh Government to 'urgently investigate and address failings in basic care.' Owain Phillips has tonight's top story.
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The Welsh Government expects all Health Boards to have robust processes in place to monitor the quality of care their patients receive, wherever it may be provided, and take action where there is cause for concern.
– Welsh Government spokesperson
A considerable amount of work is already under way to improve dementia services in Wales, including targets that have been set for the NHS to reduce the time between the onset of symptoms, and diagnosis and treatment. These targets are also being used to improve care for people with dementia in general hospital settings and to improve dignity and care as recommended by the Older People’s Commissioner for Wales. Additional financial investment is being made in this area.
Dignity in care is a top priority for the Welsh Government. All quality and delivery meetings with the health boards and trust executive teams include discussion on this area of care and where appropriate innovations and good practice are shared from other organisations.
We are committed to improving the quality and experience of care for people at the end of their life and recently consulted on a delivery plan for end of life care. The final plan will be published in the coming months.
– Graeme Francis, Age Cymru
We must all be able to access high quality care services for ourselves and our loved ones, and be certain that we will be treated with dignity and respect when we entrust care to others. Clearly, as identified by the Public Service Ombudsman for Wales, there were major shortcomings in the care received by Mrs X, with her personal hygiene, dietary requirements and physical safety neglected. Of most concern to us is that Mrs X’s final wish to die in her own bed surrounded by her family was ignored, because it had not been properly written into her care plan.
Whilst there are many examples of good care in care homes across Wales, Age Cymru is calling on the Welsh Government to work with health boards across Wales to urgently investigate and address failings in standards of basic care where they occur. There must also be mandatory human rights and dignified care training for frontline health and social care staff in Wales to ensure that dignity is always maintained.