Mr C complained to my office about the care given to his mother (Mrs M) by Cwm Taf Local Health Board (“the Health Board”). Mrs M was 86. She had a medical history which included atrial fibrillation (“AF”), Type 2 Diabetes, osteoarthritis and osteoporosis. She was taking a number of medications, including Warfarin (anticoagulation protection for AF). She was admitted to the Royal Glamorgan Hospital on 24 March 2012 because she was suffering with diarrhoea and vomiting.

Mr C said that at approximately 5.00pm on 4 April, while waiting to be discharged, Mrs M suffered a stroke. He said that despite family requests, his mother was not seen by a doctor for over six hours. Then, overnight whilst she was sleeping, she suffered a further significant stroke. Mr C said the Health Board repeatedly delayed responding to the complaint and he was dissatisfied with the way it handled the complaint and the complaint response.

My investigation considered the relevant records, comments from the Health Board and evidence provided by Mr C and his family. I took advice from an experienced physician, a Stroke specialist and an experienced senior nurse.

I upheld Mr C’s complaint because I concluded that the care provided to
Mrs M on, and leading up to, the evening of 4 April was inadequate. During her stay in hospital, by allowing the protection offered by anticoagulation to be inadequate, the Health Board failed to properly protect Mrs M from an avoidable stroke. The Health Board then failed to assess and treat her symptoms promptly and effectively. There was also a delay in her being seen by a suitably trained clinician and in transferring Mrs M to an Acute Stroke Unit.

My investigation also found that the Health Board failed to:
• follow the relevant NICE Stroke Guidance and did not have an adequate stroke protocol;
• provide (or record the provision of) appropriate nursing care;
• keep appropriate records;
• comply with Complaints Guidance.


The Health Board accepted the report and agreed to:
a) Give Mr M an unequivocal written apology for the failures identified by this report.
b) Give Mr C an unequivocal written apology for failing to comply with Complaint Guidance.
c) Make a payment to Mr M of £5500 to reflect the failings in care identified by this report; the uncertainty caused by those failings; the delays in the Health Board’s handling of this complaint and the time and trouble taken by his family in pursuing the complaint with this office.
d) So that appropriate lessons may be learned, share this report with the medical, nursing, health care and administrative staff involved in the case.
e) Provide me with evidence of the existing monitoring and quality assurance mechanisms it has in place to prevent a recurrence of:
• The failure of nursing staff to complete appropriate assessments and implement appropriate care plans.
• The failure of staff to maintain appropriate records.
• The failure of administrative, nursing and medical staff to follow the Complaints Guidance.
f) Ensure compliance with current NICE guidance and professional guidelines, by reviewing (and if needed, updating) the current policies/protocols for the:
• Management of in-patients on pre-existing Warfarin therapy.
• INR monitoring of in-patients with relevant pre-existing conditions.
(if needed, the Health Board should implement training for staff who indicate that they are not fully conversant with the relevant protocols)
g) Ensure that staff training in respect of recognising acute stroke is up to date, with particular reference to the current NICE guidance and professional guidelines.
h) Ensure that use of the NIHSS (or similarly recognised tool), in order to identify patients who are likely to have had an acute stroke, is implemented.
i) To ensure compliance with current NICE guidance and professional guidelines - review its arrangements for the identification and treatment of acute stroke and consider including the following measures:
• All patients who may have had an acute stroke should be immediately assessed by a suitably trained physician to determine whether thrombolysis is suitable.
• All patients who may have had an acute stroke should have immediate CT scanning (i.e. within one hour).
• All patients who may have had an acute stroke should be assessed immediately for admission to a specialist acute stroke unit.
• All patients who may have had an acute stroke should have a swallowing screening test (using a validated tool) by a trained professional within four hours.
j) Give my office suitable evidence to demonstrate that it has complied with the recommendations.

A full copy of the report is available below.