A public service watchdog has recommended a review of escalation procedures and training for nursing staff at a Welsh hospital, in the wake of a case involving an “appalling lack of weekend care.
A patient at a South Wales hospital died following a “complete lack of medical staff involvement” in his care over a weekend, according to an investigation by the Public Services Ombudsman for Wales. He said the case reinforced a need for a national review of out-of-hours care at the “earliest opportunity”.
“This case raises several concerns about the quality of patient care over a weekend”
The ombudsman’s report, published today, said that the patient – anonymised as Mr Y– was admitted to the Royal Gwent Hospital in Newport on a Thursday with constipation and the plan was to discharge him on the Friday as soon as he had opened his bowels.
However, due to an increase in his blood glucose levels he was kept in hospital over the weekend, despite there being a care package in place for him at home, the ombudsman found.
The report noted that Mr Y’s blood glucose levels continued to fluctuate and he had difficulty swallowing with possible aspiration.
However, nursing staff failed to inform the medical team so Mr Y was not medically reviewed at all on the Saturday, said the report.
In addition, the ombudsman highlighted that he was not assessed by the speech and language therapist, because the service “does not cover weekends”.
Then, on Sunday, Mr Y subsequently developed pneumonia. The clinician on duty was informed but failed to respond and nursing staff did not escalate their concerns to senior staff, the report said.
In fact, it was not until six hours later that a junior doctor finally reviewed Mr Y’s condition, which seriously delayed the administering of potentially lifesaving antibiotics, said the ombudsman.
“There is a need for a review of out-of-hours care at the earliest opportunity”
His “condition continued to deteriorate” and the patient “sadly died in the early hours of Monday”, the report stated.
Nick Bennett, public services ombudsman for Wales, said: “This case raises several concerns about the quality of patient care over a weekend.
“Whilst Aneurin Bevan Health Board claims that earlier medical review would not have made any difference to the tragic outcome for Mr Y and his family, I cannot be certain of that,” he said.
“I have made several recommendations to the health board including a payment of £2,000 to Mrs X for the distress caused by her father’s care, a review of its escalation procedures and training for nursing staff,” he said.
Mr Bennett added that he had previously upheld complaints against the Royal Gwent that raised “similar issues” and said that to “see repetition of these issues is troubling”.
Case highlights ‘poor weekend care’ at Welsh hospital
He noted that he had published a thematic report – titled Out of hours: Time to care – earlier this year, which highlighted “my concerns about out-of-hours care in Wales”.
“This case only emphasises those concerns, and that there is a need for a review of out-of-hours care at the earliest opportunity,” he said.
In response, Aneurin Bevan Health Board said it accepted the report’s findings and that it was “finalising a detailed action plan”, which would set out the further actions that will be undertaken to meet the recommendations outlined in the report.
Such actions included “reminding our staff of appropriate processes and escalation procedures and addressing any further training needs among nursing staff”.
The implementation of the actions will be “monitored and shared” with the Welsh Government, said a statement from the health board.
It added: “We are writing to the family of Mr Y to unreservedly apologise for the failings identified in the ombudsman’s report.”