A damning report has found patients experienced substandard care – including one who received an unnecessary amputation – at a north Wales hospital.The Royal College of Surgeons (RCS) found serious deficiencies at Ysbyty Glan Clwyd, in Denbighshire.
It followed a review of case records of 44 patients under the care of vascular services at Betsi Cadwaladr University Health Board (BCUHB).
Issues with documentation, record-keeping, consent-taking and communication between clinicians were highlighted.
'Loss of dignity'
As well as describing a “loss of dignity” suffered by some patients, the report’s findings also included:
An amputee “needing to be carried to the toilet” by his wife after being discharged without a care plan.
A patient being given an “unnecessary and futile” amputation when “palliation and conservative therapy should have been considered instead”. The report states that the risk from major amputation for the patient was “extremely high”.
Clinicians “possibly working outside the limits of their competence”.
In seven cases, clinical records did not include patient outcomes, while in six cases there were no clinical records available for the review team to assess.
The report stated: “The review team were strongly of the opinion that the majority of the surgical notes and supporting correspondence, results and reports were disorganised, illegible and incomplete.”While the review team noted good practice in some areas, nine recommendations were made, including five urgent ones “to address patient safety risks”.
Health minister Eluned Morgan said she was “disappointed and concerned” by the RCS report and expects the health board to address the issues “with immediate effect”.
She said: “The cases reviewed here involve real people and their families and there will be many others who may be worrying about the quality of the care they have received or are about to receive and whether this service is safe.“I expect the health board to address these issues with immediate effect and put a plan and processes in place to contact and review patients appropriately and sensitively, to provide them with information and assurance as well as to address the other recommendations made by the RCS.”
Vascular services were centralised from Ysbyty Gwynedd in Bangor and Wrexham Maelor Hospital to Ysbyty Glan Clwyd in April 2019.
'We must do better'
Commenting on the report, Dr Nick Lyons, executive medical director at BCUHB, said: “I am very concerned to note the review’s findings in relation to the quality and consistency of care provided. We must do better.“I am clear the board decision to consolidate the service in a hub and spoke model was the right one and is still advocated by the Royal College of Surgeons as the best for North Wales.“It should be noted that this report covers a period from 2014 through to July last year, so this is not necessarily a snapshot of where we are now, and some improvements have already taken place.”
Dr Lyons said an audit is being carried out of the quality of patient notes and documentation of patient consent across the health board. The health board has also convened a panel to oversee a review of clinical notes.“We have invested in a state-of-the-art hybrid theatre and a committed multidisciplinary vascular team, which we continue to recruit to.“New colleagues are taking up posts in the coming weeks to bolster the existing team across our North Wales network,” he added.
'Scandalous, heart-breaking and utterly damning'
The report prompted an outcry from opposition politicians in the Senedd.Rhun ap Iorwerth, Plaid Cymru’s deputy leader in the Senedd, and spokesperson for health and social care, said he "couldn’t believe what he was reading” and called for special measures to “sort out this mess”.
Mr ap Iorwerth described the findings as "scandalous, heart-breaking and utterly damning”.Sam Rowlands, the Welsh Tories’ shadow minister for local government, called on Mr Drakeford to hold a public inquiry to “restore much-needed public faith” in Betsi’s vascular services.
Mr Rowlands said: “This report once again highlights the many problems still surrounding some services in my region and my constituents deserve so much better.“I recently met with members of the Betsi Cadwaladr University Health Board to discuss this and other issues and was pleased to hear they are taking the matter very seriously.”