From Chris White, Swansea Bay Deputy Chief Executive and Chief Operating Officer.
We would again offer our sincere apologies to the family for the failings identified in this report, and the distress this has caused them.
The health board accepts that the care and treatment provided was below the standard we would expect.
We understand how difficult this has been for the family. Our Chief Executive, Tracy Myhill, has offered to meet them to gain an insight from their perspective.
We fully appreciate the seriousness and significance of the Ombudsman’s report’s findings, and accept the findings and the recommendations.
We have reflected on the learning from this case, and implemented a number of improvements to prevent this happening again.
For example, documentation spot checks are regularly carried out to identify areas of good practice which can be shared, as well as where improvements may be required.
We have strengthened our training, where appropriate, for clinical staff on recognising and treating strokes and TIAs (mini-strokes).
We’ve also launched our SAFER policy, which includes having regular multidisciplinary team briefs.
This promotes more face-to-face communication between nursing, medical and therapy staff about the needs of individual patients rather than just rely on written documentation.
We know this practice improves both the timeliness and the quality of care we provide for our patients.
A referral guide has also been produced, so clinicians are aware of the most appropriate ways to refer patients to other specialties and departments.
There is a focus on improvement work around nutrition and hydration, some of which specifically relates to stroke wards across the health board.
The health board uses a national screening assessment to identify patients at risk of malnutrition. We have revised this, and will implement a new and improved version from next month.
This will support ward staff, patients and their families to work together to meet the needs of patients at what is often a very vulnerable time.
Additionally, our nutrition teams are sharing details of the case and the Ombudsman’s findings throughout the health board, so that clinical teams can reflect and change their practice accordingly.
During December and January we chose to promote an awareness-raising campaign focusing on good practice in regard to the nutrition and hydration of our patients.
Experience tells us such campaigns are a highly effective way of reaching large numbers of staff across a complex organisation, and do lead to improved quality of care.
We recognise that family involvement in the care of their loved ones is as equally important as that of the patients themselves.
In fact, it can be more important if the patient is particularly vulnerable or unable to communicate or express their own feelings and anxieties.
Digital patient stories are a very powerful way of promoting important messages within the health board. We have invited the family to work with us on a patient story to be used for this very purpose.