Health : Betsi Cadwaladr University Health Board

Mrs A complained about the care her sister, Ms B, received at Ysbyty Glan Clwyd (“the Hospital”) between May 2019 and May 2020. Ms B sadly died on 6 May 2020.

Complaint 1
Mrs A was concerned that delays in placing stents (drains) into Ms B’s kidneys led to later complications with her condition. The Ombudsman was satisfied that Ms B’s kidney treatment was reasonable and did not uphold this part of the complaint.

Complaint 2
Mrs A complained about inadequate bowel care for her sister when she was in hospital in April and May 2020.
Ms B was in hospital mainly because she had breathing problems. But while in hospital, she needed a specific type of bowel care. This did not take place as no skilled staff were available to do it. Nurses did not update doctors that it had not been done.

Ms B developed some new symptoms. These new symptoms may have meant that Ms B had a bowel blockage, but this was not considered. She was discharged from hospital on 5 May. The Ombudsman was concerned that Ms B went home without being seen by a doctor but decided it was not possible to say that the failure to carry out the bowel care, or the lack of communication about this, contributed to Ms B’s death as she was very unwell with other problems.

The Ombudsman’s view was that the failure in bowel care meant that there was a loss of dignity for Ms B. Mrs A said her sister was embarrassed by her bowel symptoms. Dignified care is a principle in the professional framework for nurses from the Nursing & Midwifery Council. The Ombudsman also identified that Ms B and Mrs A’s rights under the Human Rights Act – Article 8, the right to respect for private and family life – should have been considered.

The Ombudsman’s investigation saw examples of poor record keeping by staff. The record keeping fell short of the requirements expected for both doctors and nurses. The Ombudsman has identified similar problems of failings in basic nursing care, in record keeping, and in communication in previous cases she has investigated about this Hospital.

The Ombudsman noted that Ms B was in hospital during the early days of the COVID-19 pandemic. They were difficult and uncertain times with stretched NHS resources. Despite that, Ms B’s care should have been of an acceptable standard.

The Ombudsman upheld Mrs A’s complaint.

Complaint 3
Mrs A was unhappy with the Health Board’s replies to her complaints.

In its replies to Mrs A’s complaints, the Health Board did not fully identify the failings that have now come to light. The Health Board’s own investigations were not thorough or open enough. The Ombudsman upheld Mrs A’s complaint about this.

Ombudsman’s recommendations

The Ombudsman made many recommendations which the Health Board accepted. These included:

• an apology to Mrs A, and payments to her totalling £4,500 for distress and having to pursue her complaint
• to share the report with staff involved in Ms B’s care for them to reflect on their actions
• to remind nursing staff at the Hospital about proper record-keeping
• to complete a Bowel Care Protocol, and to ensure that enough nursing and medical staff at the Hospital are trained to carry out manual bowel evacuation

• to review its complaint handling and responses in light of the NHS Wales Duty of Candour which will be introduced in April 2023.