Patient died 24 hours after hospital discharge failings
A patient was found dead 24 hours after being inappropriately discharged from hospital, an investigation has found.
The woman, 43, who had a history of alcohol misuse and self-harm, had taken a methadone overdose and was found outdoors suffering from hypothermia.
She was treated at Royal Glamorgan Hospital in Rhondda Cynon Taff but died at home after developing pneumonia, the Public Services Ombudsman said.
Cwm Taf University Health Board said it would address report recommendations.
The report described how the woman, known only as Ms B, was found unconscious after being reported missing.
After being taken to the hospital near Llantrisant, she was given oxygen to help her breathe and had a chest X-ray.
The X-ray was reported as clear, despite a consultant chest physician later confirming the results were not normal, the report said.
She was discharged the next day, despite still needing oxygen, after a mental health review recorded her self-harm risk as low.
But less than 24 hours later, she was found dead at home.
Her mother complained she was discharged too quickly and did not receive appropriate care.
'Inaccurate and misleading'
The ombudsman said her discharge was "troubling" for several reasons - citing a lack of clinical observations, failure to repeat tests or ensure the woman could breathe unassisted - all of which may have indicated she was developing an infection.
He said the health board's clinical director recognised several of the failings identified by the investigation but the chief executive did not acknowledge or address the clinical significance of these in correspondence with the woman's mother.
The ombudsman's director of investigations Chris Vinestock said: "It is alarming that as a result of poor discharge management, opportunities to identify Ms B's developing pneumonia were missed.
"The implications of this for her family are immeasurable."
He also said the health board's answers to her mother about the care were "inaccurate and misleading, claiming there was no evidence of any infection despite blood tests clearly indicating this was a possibility".
Mr Vinestock added he hoped the health board would address the failings identified in the report and ensure patients were no longer discharged until "all reasonable steps have been taken to ensure they are fit to do so".
Cwm Taf University Health Board's chief executive Allison Williams said: "We accept the public services ombudsman's findings in respect of this case and work is ongoing within the health board to address the report's recommendations."