Woman died after staff at Princess of Wales hospital twice failed to spot her appendicitis
A woman died after hospital staff failed to spot major problems with her appendix on two separate occasions, an investigation has concluded.
A report by the Public Ombudsman for Wales found that the patient, known as Ms F, ended up contracting sepsis as a result of a ruptured appendix and died in August 2020.
A report into her care found that clinicians at Cwm Taf Morgannwg University Health Board missed opportunities to identify and treat Ms F's appendicitis during her two attendances at the Ambulatory Emergency Surgical Unit at Princess of Wales Hospital, Bridgend, on July 17 and 20, 2020.
It concluded that staff failed to take into account the patient's severe abdominal pain, unusually low blood pressure, and blood test results which indicated the presence of a significant infection on July 17.
There were also failures to prescribe antibiotics and arrange appropriate and timely investigations, including scans, the report added.
The report said: "Instead, Ms F was sent home and told to return for a review and further investigations on July 20. This was a significant service failure.
"After a scan on July 20 ruled out gallstones as a potential diagnosis, there was a further failure to admit Ms F to hospital for more investigations into the cause of her symptoms. Sadly, Ms F did not return for further review, and she died at home on August 1, 2020."
The ombudsman concluded that if the health board had provided appropriate care on those two visits Ms F's appendicitis would have been identified and treated and her death "would have been avoided".
A statement from Ms F's family read: "We have been robbed of an incredible, bright, funny, unique, loved woman. Qualified doctors and medical professionals have been found incompetent of doing the basic things that could have and probably would have saved her life.
“For someone who had many illnesses that made her no stranger to the hospital the cause of death is minuscule in comparison and easily treated.
"The past 23 months have left us traumatised, broken, empty, angry, extremely sad just to say a few emotions that we are dealing with. This lady was just 49 years old and had so much to give and wanted to do. Those things will never be achieved now and we will be forever mourning the loss of her.
"This hospital guilty of causing her death has also been found guilty of similar violations back in 2003 when our great aunt was taken from us, again because the doctors and medical professionals failed to address her symptoms she had been shown and the correct treatment given. So our lovely family have not only had one family member taken but two.
"I wouldn't wish what we have been through and will continue to go through on my worst enemy. Things have to change, these mistakes should not be happening in this day and age."
The ombudsman launched an investigation after receiving a complaint from Ms F's cousin, Miss V, who was critical of both Swansea Bay University Health Board and Cwm Taf Morgannwg University Health Board.
The complaint against Swansea Bay UHB was not upheld as evidence showed that it was unlikely that Ms F had appendicitis when she was under that health board's care.
Commenting on the findings of the report the Public Services Ombudsman for Wales, Michelle Morris, said: "This was a tragic case and our sympathy is extended to the family. We do not make the finding of avoidable death lightly, however, the injustice to Ms F and her family could not have been more serious.
"Our investigation found no evidence that appendicitis was even considered as a potential diagnosis either on July 17 or 20 and our clinical adviser in this case told us categorically that that approach was inadequate. I am struck by the evidence from the family that Ms F did not return for review after July 20 because, based on her experience of the care provided up to that point by Cwm Taf Morgannwg UHB, she felt that that would have been of little benefit.
"Our clinical adviser in this case told us that death from appendicitis was uncommon but that death from undiagnosed appendicitis following discharge was even less common.
“Given this we were concerned that the health board's investigation of this case had not identified any learning points or recommendations despite clear indications that the management was not sufficient on either July 17 or 20.
“This, and the grave injustice to Ms F and her family, left me with no choice but to issue a public interest report on this case. I welcome that Cwm Taf Morgannwg UHB has now accepted these findings and conclusions and has agreed to implement the recommendations in full."
The ombudsman recommended that Cwm Taf Morgannwg UHB should provide a full apology to the family for the failures identified in the report and offer them independent legal advice so they can obtain appropriate financial compensation.
Paul Mears, chief executive of Cwm Taf Morgannwg University Health Board, said: "On behalf of our entire health board I express my sincere apologies to the patient's family and friends and offer our heartfelt condolences as they continue to grieve her passing.
“As a health board we accept the findings of the ombudsman and are working at pace to implement the recommendations highlighted in the report. I would like to provide reassurance to the patient's family, and to our communities, that we have put in place immediate improvements to prevent such a tragic event happening again.
"At Cwm Taf Morgannwg we are committed to putting things right and to providing the very best healthcare services our communities deserve. We will not forget this patient and take forward every piece of learning from this very sad case."