Medical staff at Ysbyty Gwynedd in Bangor missed several opportunities which may have prevented a patient’s death, a health watchdog has concluded.

The man, who was only identified ‘Mr D‘, received ‘substandard’ care at the hospital according to Public Services Ombudsman for Wales, Nick Bennett, who said: “Mr D had respiratory failure and should have been moved to a high dependency unit.”

Mr D, was admitted to Ysbyty Gwynedd in December 2014, he suffered with chronic obstructive pulmonary disease (COPD) and was diagnosed with pneumonia and respiratory failure, his daughter was later informed that Mr D’s condition was improving and plans were being made for his discharge from hospital.

However, Mr D’s condition then deteriorated and on Christmas Day 2014, four days after admission, Mr D suffered a cardiac arrest and died.

The Death May Have Been Avoided

The National Early Warning Score (NEWS), which is used to establish the degree of illness of a patient, was high and should have prompted his transferral to a high-dependency unit, but there was delay in finding Mr D a bed and he was not seen by a consultant until the following morning.

Failure to adequately monitor Mr D’s condition and a number of opportunities to escalate his care were missed, the ombudsman concluded that if his care been appropriately escalated his death may have been avoided.

The report also found that the cause of Mr D’s death was inaccurately recorded and that the initial complaint from his daughter was ‘poorly handled‘.

Mr D’s daughter, who worked for Betsi Cadwaladr University Health Board (BCUB), complained to the health board in February 2015, but didn’t receive a reply for 19 months.

BCHUB has apologised to the family, but while admitting that key observations were not carried out, they claimed these did not affect the ‘sad outcome.’

Serious Clinical Failings

The ombudsman found here were a number of ‘serious failings’ in the care of Mr D including:

  • Missed opportunities to take action which may have prevented Mr D’s deterioration and subsequent death
  • Inaccurate recording of the cause of Mr D’s death
  • Failure to carry out a serious incident report despite this being referred to in the complaint response

Mr Bennett said: “I urge the health board to learn from this case and address the serious clinical failings. By doing so, I hope that patients requiring critical care will not be overlooked in the future.”

Health board nursing executive director Gill Harris said: “We are deeply sorry for the additional distress we have caused the family, at an already difficult time, by the time it has taken us to respond to these concerns.

“We apologise that we did not deliver the standard of care that we should have and for the unacceptable delay in responding to the family’s complaint. We are working hard to improve our concerns process to make sure we provide meaningful responses in a timely manner.”

Ms Harris added that the ombudsman’s recommendations would be implemented and a progress report will be made in three months.