Betty Humphries: Cardiff and Vale health board failings criticised

Betty Humphries died in May 2017

An 88-year-old woman died after a health board did not recognise her acute kidney failure and prescribed inappropriate levels of pain relief, a watchdog has said.

Betty Humphries' family complained to the Public Services Ombudsman for Wales about her care after her death in May 2017.

Her son, Colin, said his family were "very angry" about how she was treated.

Cardiff and Vale health board said it had apologised "unreservedly".

Ms Humphries lived in Cardiff and was a former social worker and nurse.

"To receive a letter of apology 21 months later takes a bit of believing," said son Mr Humphries, from Cardiff.

"The report from the ombudsman is fairly damning of her treatment from start to finish....that there were severe service failures in the nursing care.

"That seemed to be... quite ironic as she had given her life to doing that sort of thing," he said, referring to her former work in caring professions in the Cardiff area.

Mrs Humphries had worked as a nurse and social worker in the Cardiff area

Ombudsman Nick Bennett said the failure to monitor her medication and kidney function resulted in an acute kidney injury, which was probably preventable but was overlooked.

He has made several recommendations to the health board which has accepted his findings.

The report said the health board failed to recognise that Mrs Humphries, referred to as Mrs A, was at high risk of acute kidney injury because of her age and existing health concerns, including acute kidney failure, from the time she was admitted to University Hospital of Wales.

In an attempt to control her back pain, she was prescribed pain relief at inappropriate levels due to her kidney's pre-existing condition and, even when she began to decline, this was not reviewed, said Mr Bennett.

"Failures to recognise the impact on Mrs A's kidneys, monitor her hydration or change her medication meant that it went untreated and she became more unwell and sadly died."

He also said that a prescription of an antidote to counter the accumulation of opioid pain killers, which could not be filtered by her kidneys, was prescribed too late.

Nick Bennett said the health board was awarding the family financial redress of £5,500

"There is uncertainty over whether Mrs A's death might have been avoided had appropriate action been taken sooner," he said.

The ombudsman also criticised the health board for "significant delays" in the reporting, processing, investigating and managing of two safeguarding concerns raised by Mrs Humphries' family about bruising and concerns about a possible head injury.

Health board executive nurse director Ruth Walker said it was implementing recommendations from the report.

"The health board would like to apologise unreservedly for the failings identified in the ombudsman's report into the care of Mrs A and the distress this has caused the family," she said.