A Welsh health board has been strongly criticised for its failure to consider the dignity and human rights of a patient, who died on a trolley while waiting for a bed at Gwynedd Hospital.
The Public Services Ombudsman for Wales branded the care given to the older woman by Betsi Cadwaldr Health Board as “contradictory and detrimental”.
“She did not have sufficiently considerate care in her final days”
The ombudsman noted that, following admission to Llandudno General Hospital in 2015, it had been agreed with her family that she should receive palliative care only due to her fragility and history of cancer.
However, over the next 11 days she was transferred on two occasions to Ysbyty Gwynedd, which is 22 miles away in Bangor, for CT scans that would not benefit her in any way, said the ombudsman.
The scans never actually took place and on the second visit, due to a lack of available beds and miscommunication about her condition’s seriousness, she was left on a trolley and “sadly” died.
The board admitted that an 11-day delay in the patient being seen by a consultant, due to annual leave with no arranged cover, may have contributed to her “inconsistent and indecisive care”.
In addition, the provider was criticised for the “unacceptable” length of time that it took to investigate and respond to the family’s concerns – 17 months in total.
“We are deeply sorry for the additional anxiety and distress that we caused to the patient and their family”
The board was subsequently ordered to pay the family £1,500 compensation for the level of distress resulting from care failings and the time taken to investigate the complaint.
In his report on the case, ombudsman Nick Bennett said: “Her dignity at the end of her life was not respected and she did not have sufficiently considerate care in her final days.
“The decisions to transfer her for scans, which would not have changed the approach to her care, failed to take account of her needs as an individual,” he said in his report, published today.
The board had also “failed also to take account of the patient and her family’s wider needs as part of family life”, said the report (see PDF file attached below).
Among its recommendations, it said doctors on the wards where the patient received care should be reminded of their ethical and clinical management obligations, in line with regulatory guidance.
The report also called on the board’s equalities and human rights team to identify how consideration of human rights could be further embedded into clinical practice.
In addition, it was told to consider further training in end of life care for the clinicians involved in the case and that doctors should ensure adequate holiday cover arrangements were in place.
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Mr Bennett said: “Betsi Cadwaladr’s approach to the patient’s care was detrimental to her wellbeing. Poor and inconsistent decision-making, in part due to the concerning lack of consultant cover, compromised the patient’s right to dignity at the end of her life which is a serious failing.
“In addition to the distress this caused the family, it took the health board 17 months to respond to the complaint because of a lack of ownership of the complaint, which is unacceptable,” he added.
He said: “I hope that this case will highlight the importance of embedding dignity in end of life care and human rights in clinical practice, as well as the need for timely and effective complaint handling.”
Gill Harris, executive director of nursing and midwifery at Betsi Cadwaladr, said: “We are deeply sorry for the additional anxiety and distress that we caused to the patient and their family at the end of their loved one’s life.
“We also apologise for the unacceptable delay in responding to the family’s complaint and we are working hard to improve our concerns process,” she said.
Health board criticised for ‘failing to respect dignity of patient’
“We accept all of the ombudsman’s comments and recommendations and will ensure that these are addressed as part of our ongoing work to improve services,” said Ms Harris.
She added: “The health board will continue to work closely with our clinical teams to improve the way we operate across our hospital sites to prevent a future incident of this kind.”
According to a separate report, published earlier this month, complaints made to the Public Services Ombudsman for Wales about NHS bodies have increased by 8% over the past year.
Mr Bennett described the trend as “concerning” and called on the government to “push forward” with new legislation that will “help drive up standards of public service delivery”.
The ombudsman’s 2016-17 annual report and accounts showed that it had received 2,056 new complaints about public services in Wales, compared to 1,992 during 2015-16.