Clinical treatment in hospital: Cwm Taf Morgannwg University Health Board

Mr A complained about the care and treatment his late son, Mr B received at the Princess of Wales Hospital (“the Hospital) between December 2019 and January 2021 when he experienced episodes of bleeding from the naval. Mr B attended at the Emergency Department (“the ED”) on 4 occasions: once in December 2019, once in August 2020 and twice on the same day in January 2021. On each occasion he was discharged home. In January 2021, on the day following his 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 the Health Board’s ‘watch and wait’ approach was appropriate for Mr B in December 2019 and August 2020. The Health Board’s decisions not to refer to liver specialists but to make a referral for consideration of weight loss surgery were clinically appropriate, considering Mr B’s best interests.

On 21 January 2021, Mr B attended at the ED on 2 occasions. The Ombudsman found that in respect of the first admission, Mr B should not have been sent home. This was because he had a history of significant bleeding, he was on medication to reduce blood clots, he had mild anaemia, and he also had extremely high blood sugar levels, which would likely have led to admission in its own right. Mr B was discharged home a few hours after his arrival. This decision was clinically inappropriate.

In respect of the second admission on 21 January, the Ombudsman found that Mr B’s care should have been escalated to a senior doctor. It is likely that a more senior doctor would have admitted Mr B into hospital. The decision to discharge Mr B for a second time was clinically inappropriate.

Had Mr B been admitted to the Hospital on 21 January 2021, even accepting that he would have been high risk for surgery , his deterioration and death might have been prevented. This represented a failure by the Health Board and caused significant injustice both for Mr B and his family. This aspect of Mr A’s complaint was upheld.

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. The Ombudsman found that the management of Mr B during his final hospital attendance was clinically appropriate.

The Ombudsman made a number of recommendations, which the Health Board accepted. These included:

· an apology to Mr A, and payments to him totalling £5750 for the loss of opportunity for Mr B, and for Mr A having to pursue his complaint.

· to remind all ED doctors of the recommendation by the Royal College of Emergency Medicine to escalate patients making an unscheduled return to the ED, with the same condition within 72 hours of discharge, to a consultant.

· to remind all doctors about interaction with the Coroner including the importance of providing accurate information. Also, the advisability of discussing a patient with consultant staff and a Medical Examiner following a patient’s death .

· to ensure training is provided to all junior doctors in respect of interacting with the Coroner and the Medical Examiner following a patient’s death in hospital.