A patient in care of Cwm Taf Morgannwg University Health Board dies after inappropriate discharge on two occasions

The Ombudsman launched an investigation after Mr A complained about the care and treatment his late son, Mr B received at the Princess of Wales Hospital between December 2019 and January 2021.

Mr B attended at the Emergency Department (ED) on four occasions with bleeding from the navel (belly button) caused by umbilical hernia. On each occasion, he was discharged home. In January 2021, within hours of his last discharge, Mr B suffered a further bleed and was taken to the ED where he had to be resuscitated. Mr B sadly died a day later.

The Ombudsman found that on first two occasions the Health Board’s decision to discharge Mr B was appropriate. However, when Mr B attended ED for the third time, on 21 January 2021, he should not have been sent home, and, when he attended for the fourth and final time that same day, his care should have been escalated to a senior doctor. It is likely that a more senior doctor would have admitted Mr B into hospital. On both those occasions, the decision to discharge Mr B was not clinically appropriate.

By the time Mr B was re-admitted to the ED on 22 January 2021, he was very ill. Emergency surgery at that point would have been futile and would not have been likely to save Mr B’s life. Had Mr B been admitted to the Hospital the previous day, even accepting that he would have been high risk for surgery, his deterioration and death might have been prevented.

Mr B’s death was subsequently referred by the Health Board to HM Coroner. There was no post-mortem examination. Before referral to the Coroner, the circumstances of Mr B’s death were not discussed with relevant consultants within the Health Board before it shared information with the Coroner or the Medical Examiner Service (the service provides independent scrutiny of all deaths that occur in Wales that are not referred directly for investigation to the Coroner) , although it is noted that there was no legal requirement to refer to that service at that time.

Commenting on the report, Public Services Ombudsman for Wales, Michelle Morris, said:

‘I would like to extend my sincerest condolences to Mr A and his family for the sad loss of Mr B.

The advice we have received was very clear that opportunities to treat Mr B were lost. I am certain that our finding – that, on the balance of probabilities, the outcome might have been different for Mr B had he been appropriately admitted to hospital – will cause Mr A and his family additional distress.

The clinical failings in this case were compounded by how the circumstances of Mr B’s death were relayed to the Coroner. This happened hastily and inappropriately, and without adequate supervision by the Consultants engaged with his care.’

Finally, it has also been a source of frustration to Mr A in having to pursue his complaint with us because the Health Board’s own investigation lacked both rigour and candour. We expect better of Cwm Taf Morgannwg University Health Board and all Health Boards across Wales.’

The Ombudsman recommended that Cwm Taf Morgannwg University Health Board should apologise to Mr A and to:

• pay Mr A £5750 for the loss of opportunity for Mr B to receive treatment, and for Mr A having to pursue his complaint
• remind all ED doctors that they must escalate patients making an unscheduled return to the ED, with the same condition within 72 hours of discharge, to a consultant
• remind all doctors about appropriate interaction with the Coroner and the Medical Examiner following a patient’s death in hospital.

Cwm Taf Morgannwg University Health Board has accepted the Ombudsman’s findings and conclusions and has agreed to implement these recommendations.

To read the report, click here.