We would like to take this opportunity to apologise once more to the family of Mr X and offer our sincere condolences for their loss.
We fully accept the recommendations made by the Ombudsman, and can give assurances that several important changes have been put in place over the last three years.
It remains that because of the small number of adult congenital heart disease (ACHD) patients in Wales, the surgical service continues to be provided in specialist centres in England, like the one at Bristol.
However, the management and processes supporting these patients have now been considerably tightened, and access to pre-surgical tests within Wales much improved.
The Welsh Health Specialist Services Committee (WHSSC) has provided additional funds to health boards to improve ACHD services.
As a result, individuals have been appointed within health boards to manage ACHD patients and provide weekly clinics. Cases are now presented weekly at Bristol, and many of the cardiac investigations – including trans-oesophageal echocardiograms; CT scans and angiograms are now undertaken in health boards’ hospitals.
Clinical Nurse Specialists have been appointed to manage ACHD patients and improve communications, and information for patients has also been improved overall.
However we know there is still more that can be done to improve the service for ACHD patients, and we are seeking support from WHSSC for further improvements for these patients to access expert opinion, diagnostics and treatment.
A copy of the Ombudsman's report is available here.
We wish to apologise sincerely to the family of this patient for the shortcomings in his care, and the distress this has caused. Triaging patients effectively and providing adequate and timely pain relief are extremely important, and we have since taken significant steps to improve these aspects of our care.
There have been considerable changes in the Emergency Department (A&E) at Morriston Hospital over the last two years; including major triage and pain management improvements.
The department has increased the numbers of nurses, and further increases in the number of triage nurses are planned shortly. A nationally-recognised triage system has been introduced to ensure patients’ conditions are assessed as accurately as possible. Alongside this, new systems are in place to reduce delays for patients waiting to see specialist teams.
There has been a big focus on improving pain management, and staff now have much easier access to pain relief medication to ensure patients are treated more rapidly. Strong painkillers are pre-prepared to reduce the time needed to set up and administer pain relief, and the department has a robotic pharmacy system which can dispense medication quickly.
Changes have also been made around the way care is provided to Musculo-Skeletal patients which enable consultants to review Emergency Department patients much earlier. Action has also been taken to ensure all doctors respond to ‘red flags’ which indicate a potentially urgent issue around back pain.
The Health Board is also investing in a new IT system developed to track where patients are in real time, which will automatically flag up any delays or waits. This is scheduled to go live towards the end of 2014.
Improvements within the Emergency Department are evidenced in a new report of an unannounced dignity and essential care inspection at Morriston’s Emergency Department, carried out by Healthcare Inspectorate Wales in February 2014.
It says: “Discussions with patients indicated that staff responded promptly to requests for pain relief, and patients appeared comfortable. We found pain relief charts and assessments were used and pain relief was administered promptly, where this was necessary.”
The report, published by HIW on 30th May, summarised: “Overall, patients can be confident that the service at Morriston is well run, with due care and attention to professional standards of care.
“We found very well established monitoring arrangements regarding patients’ experience of care, clinical practice, safe systems of working, staff training and development and the wider aspects of organisational development.”
A copy of the Ombudsman's report is available here.
We would like to offer our sincere apologies to the patient’s family for the aspects of her care, highlighted in the Ombudsman’s report, which did not meet the high standards expected of us.
We have accepted all of the Ombudsman’s recommendations. Several improvements have already been made, or are underway, including additional staff training and better record-keeping.
In May - partially in response to a draft of this Ombudsman’s report - ABMU Health Board set up a clinically-led senior team specifically to investigate concerns about some of the care delivered at the Princess of Wales Hospital, and to instigate urgent changes. The focus of this work has been on the Emergency Department and the Clinical Decision Unit, (and also medical wards.)
The Board and clinical team have acted swiftly, and already significant actions have been put in place. One of the first moves was the appointment of a Chief Nurse for the hospital. An Assistant Medical Director with a specific focus on the hospital has also been appointed.
A huge emphasis is being placed on re-training. For example, over the last six weeks eight training sessions have been held on Early Warning Scores, which help nurses recognise signs of a patient deteriorating. Several other re-training programmes are also underway.
30 nurses are also being appointed to the hospital, and we plan to increase the number of senior nurses in the Emergency Department.
While we are confident that the majority of patients have a positive experience at the Princess of Wales Hospital, we are aware that some patients have not received the standard of care expected of us. We are determined to put that right.
A copy of the Ombudsman's report can be found here.
ABMU's response to the Ombudsman's Report published today (Thursday 11th April 2013) about the care of a patient at the Princess of Wales Hospital, Bridgend:
“We would like to take this opportunity to once again express our sincere condolences to Ms A and the family and friends of Mr B.
“The Health Board fully accepts the recommendations of the Ombudsman and would like to take this opportunity to apologise to Ms A publicly for our failings.
“The safety and quality of care of all our patients is very important and the consent process is a crucial part of this. Although these tragic events involve one individual patient and one clinical team we recognise that it is something we can all learn from; especially the importance of identifying, discussing and ensuring patients fully understand all risks.
“The staff involved have reflected on what happened with colleagues and peers, not only to learn from the case itself, but to benefit from the experience and perspective of others.
“In addition to the recommendations in the report, the Directorate has identified a number of lessons with regard to the management of serious case reviews and importance of robust communication. This will ensure that in future we are able to give a clear view from the organisation and not just the department or directorate involved.”
Ombudsman’s report published 11th April 2013
ABMU's response to the Ombudsman's Report published today (Tuesday 26th February 2013) about the care of a patient at Singleton Hospital, Swansea:
We would like to once more offer our sincere condolences to the family of this patient for their very sad loss, and apologise for the failings in her care identified in the Ombudsman’s report. The Health Board fully accepts the findings and recommendations of the Ombudsman.
Patients contacting the ambulance service with similar symptoms would be taken to Morriston Hospital, but in this particular case the patient presented independently of the ambulance service directly at Singleton Hospital.
Staff at Singleton Hospital liaised with colleagues at Morriston Hospital and conducted a number of tests which eventually resulted in the correct diagnosis of this rare condition. There were however unacceptable delays in significant aspects of the management of this patient’s care.
Whilst staff at Singleton Hospital did their best to diagnose and treat the patient; the patient sadly died.
Our ongoing Changing for the Better programme, which is considering ways to improve the way the health Board delivers NHS care, is looking at the provision of acute general medicine provision in Swansea. We will be taking the lessons learned from this case into consideration as part of this ongoing focus on acute medicine.
Ombudsman’s report published 26th February 2013
Appendicies 1 to 5 for Ombudsman’s report published 26th February 2013
We would like once again to offer our most sincere condolences to the family of this patient for their sad loss; and to apologise for the shortcomings in important aspects of care this patient received, which we acknowledge fell well below the high standards expected.
We would like to give assurances that there have been major changes since the time this patient was an inpatient at Cefn Coed Hospital, particularly around pressure ulcer prevention.
Today, our hospitals have some of the lowest rates of pressure ulcers in the world. In 2008 pressure ulcer incident rates stood at 13% (over 400 incidences a month), which was typical for the NHS but by December of 2012, the rate had decreased to <1% (just 2 incidences across 2300 beds during the whole month of December).
Pressure sores are not acceptable, and in almost all cases they are avoidable. Our clinicians have been determined to find ways to greatly reduce the risk of patients developing pressure ulcers, and in 2008 we began a major programme developing interventions to prevent pressure ulcers.
We successfully piloted this early work in 2009, in a small number of acute wards. As our staff underwent training, we were then able to steadily roll out these interventions, known as the SKIN bundle, across ABMU.
They are now in use at all our hospitals, where nine wards have prevented patients developing any pressure ulcers for over three years; and a further seven wards have stopped pressure ulcers for over two years. We are currently working with nursing homes, and starting to work with residential homes, to spread this good practice further.
Sadly, at the time this patient was in Cefn Coed Hospital, the SKIN bundle had not yet been rolled out to that hospital. It was implemented at Cefn Coed Hospital in September 2010, and since then there has not been a single incident of an inpatient using the ward (which has since transferred to a new facility) developing a pressure ulcer.
In response to other concerns raised in the Ombudsman’s report; the physical ward this patient was in is no longer in use. It was replaced in 2012 by new wards in Ysbryd y Coed, a new £18 million unit in the grounds of Cefn Coed Hospital, which was purpose built and designed for patients with dementia.
The end of life care pathway used in 2010 is no longer used by the Health Board. We now follow the All Wales Integrated Care Priorities for the Last Days of Life, and this is monitored regularly by doctors. We also have better mechanisms in place to assess and serve patients’ nutritional needs.
In addition, we have introduced a quality and safety system into mental health services which closely monitors the standards of care on wards, including nutrition; infection control, adherence to the SKIN bundle and training and education, among others.
We realise that elderly people are among the most vulnerable patients in our care. ABMU Health Board strives to continually improve the care and services we are able to provide for them, and to learn lessons when we get it wrong.
Ombudsman’s report published 15th February 2013
Today, Wednesday, 28th September, a critical report has been published by the Public Services Ombudsman for Wales regarding the care of one of our patients who tragically died.
We have offered our sincere condolences and apologies to the family of this patient. We are truly sorry that the patient, while in one of our wards, received care which fell well below acceptable standards.
After his tragic death a Protection of Vulnerable Adults investigation identified shortcomings and we swiftly took action to make the improvements and changes needed to ensure that we now offer the highest standards of care.
These included increasing the number of nursing staff, appointing a new ward sister, and ensuring that the ward based staff completed an education and training programme.
Procedures have also been tightened and improved, including the introduction of an ABM-wide ‘traffic light’ system which reflects the individual needs of patients with learning disabilities within their individual care plans.
In addition to these improvements, we have already begun implementing the recommendations made by the Ombudsman in his report.
As a result we want to assure the public that the ward today has improved significantly from the way it was over two years ago. In fact, it is now a pilot ward for a scheme called “Transforming Care” which focuses on staff spending more time on direct patient care.
We can also give assurances that we have used the experience of this tragic event to improve our practices across the Health Board.
Whilst we fully recognise that this can be of little comfort to the family it is important that they know that the concerns that they have raised have improved care for others. We would wish to reiterate our sincere apologies to them for failing to meet the needs of this patient.
The Ombudsman's Report 28th September 2011
The Public Services Ombudsman for Wales has investigated a complaint against Dr R.D. Bohra and has sent the report on his investigation to Dr Bohra. The complaint related to failure to refer a patient appropriately.
A copy of the report is available on the Local Health Board Website: Ombudsman Report December 2010.
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