Bronglais Hospital diabetic patient's records 'falsified,' watchdog finds

The public services ombudsman has raised concerns over clinical record keeping at Hywel Dda Health Board.

It comes as a report found staff at Bronglais Hospital in Aberystwyth, falsified the records of a diabetic man, who died a few months later.

Peter Tyndall said he had seen "several" other instances where records had been amended.

Hywel Dda Health Board has apologised to the 80-year-old's family and says it accepts the findings of that report.

Mr Tyndall upheld a complaint by the man's daughter about the care offered and the "inadequate" response to her complaint.

He backed the account given by the woman, referred to as Ms R, after her father was admitted in December 2008.

She said the hospital failed to record important information about her father's diabetic regime and did not monitor his blood sugar properly.

She complained to the ombudsman that nursing staff amended her father's records to hide failures over his blood sugar monitoring.

The monitoring failures, she believed, led to her father having a hypoglycaemic attack, contributing to his heart attack.

He died in April 2009.

In his conclusion the ombudsman found "there appeared to be a deliberate attempt to cover up the lack of blood sugar monitoring".

Speaking on Wednesday, he told BBC Radio Wales he had seen other cases from Hywel Dda Health Board which showed records had been changed after an event to make them look better.

"It's very clear that monitoring at the hospital wasn't good," he said.

"In the course of our investigation we discovered that even when doctors had specified - as they had in this instance - that someone should be monitored every four hours, the practice was to monitor them every six hours, which clearly was inadequate.

"But in this case even that didn't happen.

"We seen a lot of [NHS] cases now where monitoring has not been properly undertaken and when it has been undertaken it hasn't been properly documented.

"And then, even when it has been undertaken and documented, people haven't acted on what they are seeing. So we think that there is a serious difficulty.

"It can be related to a shortage of staff but it isn't inevitably so. This is about practices that are not being properly managed on wards.

"What compounded this case is that when the person complained, it was evident that the health board didn't deal with their complaint properly and the issues that came to light in my investigation didn't come to light in theirs.

"So clearly they weren't in a position to learn the lessons from their mistakes in this instance.

"And we found as well that some of the records had been falsified to give the impression that the monitoring had happened more frequently that in fact it did.

Peter Tyndall described the amending of records as 'very concerning'

"I think there's a characteristic about this one particularly of amending the records after the event to make it look better, which we've seen in other cases from Hywel Dda and clearly that is very concerning."

Hywel Dda Health Board director of nursing and midwifery Caroline Oakley apologised to the patient's family again for care that "fell below the standards expected".

She said: "Since 2008, when this incident occurred, we have put in place numerous measures, including extra training for nurses in diabetes care and a review of the blood monitoring equipment.

"We are committed to on-going improvements, specifically for the growing number of patients living with chronic conditions, to ensure that we provide a patient-centred approach for every individual in our care."

Later the health board issued a further statement.

"We are aware of one historic case related to a formal organisation where the ombudsman raised this as an issue," said a spokeswoman.

"The health board takes seriously any allegations of breaches of professional standards and it will always investigate these, as it did with the previous case."

"All nursing staff have been reminded of the professional standards expected of them."

'More questions than answers'

In a statement, the patient's family said: "One element of the complaint has been the falsification and subsequent disappearance of clinical records.

"Tampering with nursing documentation is professional misconduct and a criminal offence.

"We are disappointed that the 'superficial and untimely' nature of the complaints procedure at the Bronglais means that those nurses responsible will never be properly held to account for their actions.

"This is not the first time that the ombudsman has had reason to criticise the Bronglais for falsifying clinical records.

"We are pleased that the ombudsman has taken the unusual step of referring this case to Healthcare Inspectorate Wales.

"As far as the family are concerned, we feel the report poses more questions than answers. For this reason, we are determined to ensure that this is not the end of the matter."