Board criticised for taking three years to respond to a complaint

AHEALTH board has been heavily criticised in an ombudsman’s report for taking more than three years to respond to a complaint about a woman’s death.

Mr D, as he is known in the report, complained to Cwm Taf University Health Board about the care and treatment of his mother (Mrs D) following her death at the Royal Glamorgan Hospital in 2012.

Despite admitting there had been a breach in their duty of care and promising to investigate the matter further, Mr D heard nothing from the health board for nearly two years.

The health board claimed the original complaint record was misplaced in a “culling exercise”.

In September 2015, when the health board had still failed to respond, the Public Ombudsman for Wales contacted Cwm Taf’s chief executive who agreed to pursue his complaint as a “matter of urgency”.

But a year later, with Mr D having heard nothing further, the ombudsman began an investigation into the complaint.

It found that the health board had failed to offer Mr D free legal advice and the opportunity to jointly instruct an expert clinician to consider his mother’s care.

It also concluded that the failings identified were not the cause of his mother’s death but failed to inform Mr D this decision had been reached without her clinical records, which it had misplaced.

Public Services Ombudsman for Wales Nick Bennett said: “This was at best a lack of transparency and at worst an attempt by the health board to mislead, potentially jeopardising patients’ faith in the Putting Things Right process.

“While I cannot change the sad outcome for Mrs D, I hope that the health board will learn from this experience and ensure future complaints are dealt with in a timely and compassionate way.”

Mrs D was admitted to the Royal Glamorgan Hospital in November 2012 with respiratory failure, infection, low blood pressure and impaired kidney function.

The report states she had at least two medical reviews the following day but deteriorated rapidly and died at 5.15pm.

Mr D complained to the health board in March 2013 and seven months later he received a response.

Cwm Taf accepted there had been poor monitoring of his mother, poor communication between nursing and medical staff, and this had resulted in a failure to escalate the deterioration in Mrs D’s condition in a timely manner.

The health board apologised for the failings identified and acknowledged these amounted to a breach in their duty of care.

But, despite stating an investigation would be carried out, Mr D heard nothing “substantive” from the health board for three years.

The ombudsman upheld Mr D’s complaint and recommended that the health board apologise to Mr D, offer him £2,000 for the distress caused and £500 for pursuing the complaint. He also urged Cwm Taf to give him free legal advice to consider whether Mrs D had suffered harm as a result of the shortcoming the health board identified.

If it was not possible to arrange this, the ombudsman recommended that Mr D be paid a further £1,500 to reflect the “lost opportunity” to have his mother’s care considered appropriately.

In response, Allison Williams, chief executive of Cwm Taf University Health Board, said: “We accept the Public Services Ombudsman’s findings and we reiterate our sincere apologies to the family for the failings identified within the report.

“We have already taken a number of actions to improve and strengthen our complaints processes.”