A 71-year-old cancer patient died after a Health Board provided her with a “very poor standard of care”, the Public Services Ombudsman for Wales has found.

The Ombudsman launched an investigation after receiving a complaint about the care given to Mrs X (anonymised) in December 2019 by Cwm Taf Morgannwg University Health Board.

The Ombudsman found that a “catalogue of failings” led to the Health Board failing to diagnose pneumonia in the patient for an “alarming” 12 hours, leading to a “significant delay” in administering appropriate treatment. As a result, Mrs X died the day after her admission to Prince Charles Hospital in Merthyr Tydfil.

He also found that a 15-hour delay in administering antibiotic treatment, during which Mrs X was nursed in a hospital corridor, led to her untimely and “avoidable” death.

In addition, the investigation found that there was a “considerable delay” in administering oxygen, even when Mrs X’s oxygen saturation levels were recorded as low, which may have contributed to the aspiration that caused her death. Furthermore, the Ombudsman’s report found that Mrs X’s care was “compromised” due to being nursed in the corridor of an over-capacity emergency department. The report also found that pressure in the emergency department, and low staffing levels, may have contributed to the “poor care” that Mrs X received.

The Ombudsman also criticised shortcomings in the Health Board’s response when Mrs X’s husband complained about his wife’s treatment. By failing to thoroughly investigate Mr X’s complaint until the Ombudsman launched his investigation, he found that the Health Board contributed to a prolonged ordeal for Mrs X’s family, which was “distressing and potentially unnecessary”. He found that that this resulted in a delay in identifying the “serious shortcomings” in Mrs X’s care and vital lessons being learned.

Commenting on the report, Nick Bennett, Public Services Ombudsman for Wales, said:

“This is a distressing case where the catalogue of failings I have identified contributed to a very poor standard of care for Mrs X, and denied her the opportunity to spend the little time she had left with her family. This deeply saddens me, and I wish to convey my heartfelt condolences to Mr X and the family.

“My report has identified several areas where the care received by Mrs X fell far below what she and her family should have expected. There were several serious service failures in this case, and the consequent injustice to Mr X and her family is immeasurable.

“Not only did Mrs X not receive a timely diagnosis or appropriate treatment, but the failure to do so had a fatal outcome in this tragic case.”

Cwm Taf Morgannwg University Health Board has agreed to several recommendations, including:

• Providing awareness training for all emergency department staff on the correct use of the National Early Warning Score (NEWS) system – a tool developed to improve detection and response to clinical deterioration in adult patients.
• Carrying out an audit of a sample of patient records to ensure that staff have escalated appropriately where required.
  • Providing a full written apology to Mr X for the significant failings in his wife’s care and the distress caused to the family, which meant that they were denied what little time they had left with Mrs X.

Protector of Citizens, Mr. Zoran Pašalić, head of the NPM, Ms. Nataša Tanjević and the Department experts, accompanied by Mr. Đorđe Alempijević, forensic doctor, carried out an unannounced and detailed control of the conditions in which children with disabilities live in the Home "Kolevka" in Subotica.

"On Saturday, 24 July 2021, we investigated whether the conditions in this Home were in line with the needs of children with disabilities. Considering that the control was unannounced, I believe that what we found there was the real state of affairs in the Home", said the Protector of Citizens, Zoran Pašalić.

Pašalić said that more than 100 children with various types of physical and mental disabilities were accommodated in the Home for Children with Disabilities "Kolevka", where some of them had multiple disabilities, and all of them needed special care and attention.

"It is very difficult to remove some of the children to a foster family due to the need of 24-hour care by medical experts from different specialties", said Pašalić.

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Desde el Síndic, defendemos la petición de un vecino de Mislata de acceder a sus informes médicos de manera electrónica y consideramos que es “absolutamente clara” la obligación que tiene la Administración sanitaria de poner los medios necesarios para respetar y cumplir con este derecho de relacionarse con la administración a través de medios electrónicos.

Nuestra actuación se inició a mediados de abril cuando recibimos la queja de un ciudadano, perteneciente al área de salud de Manises, que nos trasladaba sus dificultades para solicitar de manera presencial sus informes médicos. Concretamente alegaba problemas de desplazamiento en el transporte público y estancia en espacios cerrados en la actual situación de pandemia; pero sobre todo se quejaba de que, para hacer dicho trámite, “solo se habilitan los martes de 9:00 a 14:00 horas, presencialmente, se rellena la solicitud y luego hay que esperar a que te avisen y volver de nuevo”. El interesado consideraba que deberían habilitar una vía electrónica para obtener los informes de forma más inmediata y sencilla.

La actual legislación en esta materia (Ley 39/2015, de 1 de octubre, del Procedimiento Administrativo Común de las Administraciones Públicas) incorpora la tramitación electrónica como el medio habitual de la Administración al relacionarse con los ciudadanos. En concreto, el artículo 14 de esta ley establece que toda persona tiene derecho a elegir en todo momento cómo quiere comunicarse con la Administración Pública a la hora de ejercer sus derechos y obligaciones, es decir, si lo quiere hacer a través de medios electrónicos o no. Por lo que es evidente la obligación de la Administración de ofrecer medios electrónicos para relacionarse con la ciudadanía.

Para más información, consulta nuestra resolución sobre este asunto.

Leeds City Council failed to follow guidance on summer-born admissions when deciding when an August-born girl could start school, the Local Government and Social Care Ombudsman has found.

The Ombudsman heard the girl’s mother had applied to postpone her daughter’s school start last year, because she felt it was not in her best interests.

A panel set up by Leeds City Council considered the mother’s application, but applied the wrong test. Instead of deciding whether the girl should join reception or Year 1 in 2021, it looked at whether she should start reception in 2020 or 2021.

The council decided the girl’s needs could be fully met in her chronological year group and it would not be in her best interests for her to start out of that year group. It said the girl should start reception in September 2020 and if her mother declined she would need to apply for a Year 1 place in 2021.

The mother complained to the council and explained why she thought it had not made the right decision, but the council did not properly take into account her concerns.

Michael King, Local Government and Social Care Ombudsman, said:

“The key point in this case is that the parent decides when their child starts school, and the council decides in which year group.

“Government guidance states admission authorities must make decisions based on a child’s individual needs and abilities and consider whether these can best be met by them starting school in reception or year one.

“They should also take account of the potential impact of being admitted into year one without first having completed the reception year. In this case, the council did not do this and so we have found fault with its decision-making process.

“I am pleased the council has accepted my recommendations to improve its decision making for other young children in the city.”

The girl has now been given her place in her chosen school.

The Local Government and Social Care Ombudsman’s role is to remedy injustice and share learning from investigations to help improve public, and adult social care, services. In this case the council should apologise and pay the mother £150 for her time and trouble in bringing the complaint.

The Ombudsman has the power to make recommendations to improve processes for the wider public. In this case the council has agreed to review all pending and recent decisions in the last 12 months covering requests from parents of summer-born children for delayed entry to reception. It will consider whether those decisions have been properly made, following the School Admissions Code and Government guidance, and remake any decisions that have not done so.

The council will also provide the Ombudsman with a copy of the review and provide training to panel members and relevant council officers on summer-born admissions to ensure the correct decision-making process is followed when considering future applications.