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Health board admit failure for misdiagnosing pregnancy

Cardiff and Vale University Health Board’s Executive Director of Nursing, Ruth Walker, offered the Board’s unreserved apologies to Emily Wheatley for misdiagnosing her pregnancy. The Board has accepted the Ombudsman’s recommendations and assures the public it has now updated it's protocols.

"We do not underestimate the distress we have caused and are genuinely sorry that it has taken an Ombudsman’s report for her to receive the answers she deserved. What happened is absolutely unacceptable"

“While we now have protocols in place within the Obstetrics and Gynaecology directorate that comply with best practice, we have decided to go beyond the Ombudsman’s recommendations and undertake a review of the way we care for women in the early stages of pregnancy. "

The Health Board understands there may be current or former patients who have concerns about their experience of early pregnancy scans whilst in their care. They've opened a helpline to support anyone who wants to talk through issues relating to their care. The UHB helpline number is 0800 952 0244

  1. Rob Shelley

Man died as hospital didn't tell him he had liver disease

The Public Services Ombudsman has ordered one of Wales leading hospitals to pay £5,000 compensation to the family of a 30-year-old Rhyl man who died, needlessly, from liver disease.

Carl Nolan was born with cirrosis of the liver and diagnosed with the condition a decade before he died - but no-one told him of the findings until it was too late.

Today Wales' medical ombudsman ruled that Carl's death was wholly avoidable.


Health board admits care given was 'below standard'

A north Wales health board says the treatment given to Carl Nolan, who died of liver disease at the age of 30, was not up to scratch:

We have received the Ombudsman's report and accept its findings in full. The health board recognises that some of the care given was below the standard that should have been provided to the patient and family.

We fully accept the recommendations in the report and have taken action to address each one made. We are reviewing our appointment system and process, and gastroenterology care pathways to provide an improved and more robust safe service for patients.

We are also making sure that safeguard measures are implemented to improve our standards of engagement with patients while they are treated by the health service in North Wales.

– Angela Hopkins, Betsi Cadwaladr University Health Board

Hospital denied dying man 'opportunity to survive'

Carl Nolan, who was born with liver disease, died aged 30 after a hospital failed to inform him of his condition. Credit: Family Photograph

A man who was born with liver disease died at the age of 30 following a catalogue of errors by his local health board which - ultimately - prevented him from having a transplant.

Unbeknown to him Carl Nolan had cirrhosis - a life threatening condition - but when he became ill and visited Glan Clwyd Hospital in Bodelwddyn, Denbighshire, staff failed to tell him about his complaint and he went without any medical treatment for several years.

Eventually when his liver was failing Mr Nolan was admitted to hospital but died three days later.

In a report published today the Public Services Ombudsman for Wales says: "Had he been treated three days earlier, Mr Nolan should have recovered from the infection and had a chance of receiving a liver transplant. This opportunity to survive and flourish was denied to him."

Betsi Cadwaladr Health Board has agreed to write to Mr Nolan's family to acknowledge its failings and pay them £5,500.

Ombudsman: 'pattern of failures' in the care of dementia patient at Cefn Coed 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 'considering next steps' over Ombudsman report

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

– Healthcare Inspectorate Wales

Ombudsman: 'Cultural change needed' for end-of-life care

'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."

ABMU Health Board: 'major changes made' since dementia patient's death

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.

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.

– Abertawe Bro Morgannwg University Health Board

Ombudsman criticises dementia patient's care

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.

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