'Failings' led to Glan Clwyd patient death, report finds
A north Wales health board has been criticised for "fundamental clinical shortcomings" which led to a patient's death, an ombudsman's report has said.
A man, referred to as Mr M, was admitted to Glan Clwyd Hospital for bowel cancer surgery in September 2014.
But test results showing a leak were not properly reviewed, his condition deteriorated and he died a day after emergency surgery, the report said.
Betsi Cadwaladr University Health Board has apologised for its failings.
The Public Services Ombudsman for Wales, Nick Bennett, also criticised the "deplorable length of time" it took the health board to deal with the subsequent complaint about the failings.
Mr M's daughter, referred to in the report as Ms A, complained to Mr Bennett after concerns she raised several times about her father's post-operative care with nursing staff were ignored and not documented.
She believes this ultimately led to his death.
Questions were also raised about the integrity of the health board's investigation into Mr M's care, which failed to recognised the failings highlighted by the ombudsman's investigation and his conclusion the care had been appropriate.
The report highlighted serious clinical deficiencies including:
- A failure to recognise and monitor Mr M's abnormal blood levels as well as other warning signs that he was not recovering as he should be
- A lack of senior review of vital blood test results which led to missed opportunities for early intervention
- A failure to carry out basic sepsis management
Mr Bennett said: "Whilst I accept that any surgery carries with it a degree of risk, I cannot ignore the likelihood that, had clinicians intervened sooner in Mr M's post-operative care, the outcome could have been very different.
"Mr M's family will never be sure whether his death could have been avoided and will have to live with knowing that there were missed opportunities for potentially life-saving treatment, which is a significant injustice.
"I am also extremely disappointed that the health board's review of Mr M's care fell significantly short of what I regard as acceptable, as well as taking a deplorable length of time to respond to Ms A's complaint."
Recommendations include making an £8,000 payment to Ms A for distress caused.
Mr Bennett said there was a wider issue across Wales regarding "clinical leadership and support for junior doctors during out-of-hours periods - that's a conversation I've had with the government".
Betsi Cadwaladr chief executive, Gary Doherty said the board "fully accept" the ombudsman's views over shortcomings and the fact "we may have missed an opportunity" to save the patient's life.
"I am truly sorry for this, and that we then took far too long to respond to the family's initial complaint," he added.
Mr Doherty said he would contact the family to apologise and said the report was being shared with clinical staff involved and wider medical teams.
He also said the report recommendations would be "implemented in full".