AN ELDERLY patient receiving end of life care who was transferred on two occasions to a hospital 22 miles away for "unnecessary" scans was denied her dignity and human rights, according to the Public Services Ombudsman for Wales.
The woman died on a hospital trolley. Ombudsman Nick Bennett hit out at Betsi Cadwaldr University Health Board (BCUHB) saying there has been “serious failings” and branded her care “contradictory and detrimental”.
The patient, known as Mrs X, was admitted to Llandudno General Hospital in 2015 in a serious condition. Following a review, it was agreed with Mrs X’s family that due to her fragility and history of cancer she should receive palliative care.
Over the next 11 days, she was she was transferred on two occasions to Ysbyty Gwynedd for CT scans that “would not benefit her.” The scans never took place and on her second visit, due to a lack of available beds and miscommunication about the seriousness of her condition, Mrs X was left on a trolley where she died.
BCUHB admitted there was a delay in Mrs X being reviewed by a senior doctor during her time in hospital because the consultant was on annual leave with no arranged cover, which may have contributed to her “inconsistent and indecisive care”.
Mr Bennett said: “BCUHB’s approach to Mrs X’s care was detrimental to her wellbeing.
“In this case poor and inconsistent decision-making, in part due to the lack of consultant cover, compromised Mrs X’s right to dignity at the end of her life which is a serious failing.
“In addition, it took the Health Board 17 months to respond to Mr Y’s concerns because of a lack of ownership of the complaint which is unacceptable.
“Whilst I cannot change the sad outcome for Mrs X and her family, I hope this case will highlight the importance of dignity in end of life care and human rights in clinical practice, as well as the need for effective complaint handling.”
Gill Harris, executive Director of nursing and midwifery at BCUHB, said: “We are deeply sorry for the additional anxiety and distress we caused to the patient and the family at the end of their loved one’s life.
“We also apologise for the delay in responding to the family’s complaint.
“We accept all of the Ombudsman’s comments and recommendations and will ensure these are addressed as part of our ongoing work to improve services.”