'Catalogue of failings' in Merthyr Tydfil sepsis death
A report has found a "catalogue of serious failings" led to the death of a man who developed sepsis in hospital.
The 55-year-old, referred to as Mr Y, died at Prince Charles Hospital in Merthyr Tydfil in April 2015.
The public services ombudsman said sepsis in Mr Y should have been identified and treated sooner.
Chief executive Allison Williams said Cwm Taf health board "would like to reiterate our sincere apologies to the family for the failings identified".
Sepsis, also known as blood poisoning, is the reaction to an infection in which the body attacks its own organs and tissues.
Ombudsman Nick Bennett said doctors failed to notice a perforation in Mr Y's bowel soon enough, prompting him to develop sepsis.
He was discharged from hospital after complaining of severe abdominal pains.
Although this was deemed to be reasonable, he was readmitted within days after being found confused and suffering from hypothermia.
Mr Bennett listed five failings, including missed opportunities to recognise the seriousness of Mr Y's condition and a delay in starting him on new medication.
Mr Y's sister, called Mrs X, was paid £4,500 by the health board for the shortcomings in her brother's care.
"My investigation has highlighted a catalogue of serious failings with regards to the care and treatment of Mr Y and sadly we will never know if the outcome would've been different had he been treated in the correct manner with surgery taking place sooner," said Mr Bennett.
"This is a tragic injustice for Ms X and I can only hope my investigation brings her some kind of closure."
Ms Williams said the health board accepted the ombudsman's findings and had agreed to implement his recommendations.
What are sepsis symptoms?
The UK Sepsis Trust lists six symptoms to be aware of:
- Slurred speech
- Extreme shivering or muscle pain
- Passing no urine in a day
- Severe breathlessness
- It feels like you're going to die
- Skin mottled or discoloured