Hospital patient Carl Nolan's death criticised by ombudsman

One of the "worst examples of poor treatment" led to the death of a man who was not told he had been diagnosed with a life-threatening condition, said a watchdog.

Public Services Ombudsman Peter Tyndall upheld a complaint by the family of Carl Nolan, 30, of Rhyl, who had congenital cirrhosis of the liver.

Mr Nolan had been treated at Glan Clwyd hospital.

Health bosses said required standards were not met but changes had been made.

The ombudsman's report, which refers to Mr Nolan as Mr X, said he was born with cirrhosis of the liver and diagnosed with the "life-threatening" condition - which replaces healthy tissue with non-functioning scar tissue - in 2000 but neither he nor his family were told at the time.

And although a follow-up outpatient appointment was made for him in 2001 the IT worker was not notified, said the report.

He became ill again in 2008 and was given treatment but investigations to determine the cause were not concluded.

It was not until he requested a second opinion that he was told he had been born with cirrhosis.

The report was not able to establish why Mr Nolan had not been initially told of his condition or given advice about how he could make lifestyle changes to improve his health after diagnosis of the condition.

In 2010, he was admitted to hospital several times in quick succession after becoming ill again and blood tests showed that "his liver was failing".

But the hospital "sent him away, only finally admitting him three days after his appearance" with a serious infection and before finally being referred for specialist treatment. He died seven weeks later.

'Catalogue of errors'

The report said: "Had he been treated three days earlier, Mr X should have recovered from the infection and had a chance of receiving a liver transplant. This opportunity to survive and flourish was denied him."

In an interview with BBC Wales, Mr Tyndall said: "If he had been appropriately and promptly treated, his family are left with the knowledge that he could still be with us today.

"He was a young man with his life ahead of him, a partner, a loving family, and all that was taken away.

"I was shocked by what our investigation found in this instance.

"This is one of the worst examples of poor treatment and poor communication with a patient that I have encountered in my time as ombudsman."

He upheld the family's complaint and issued recommendations to hospital manager Betsi Cadwaladr Health Board to review its "care pathway" and appointments system as well as its complaints handling process.

Mr Nolan's mother Pat, a call centre supervisor, said had he been advised about his diagnosis in 2001 he could have sought and received specialist help and advice to improve his condition and could, ultimately, be alive today had he been able to receive a liver transplant.

Mrs Nolan said: "This is a catalogue of errors and everybody along the line is accountable for Carl's death because they knew what he had and no one saw fit to communicate that and act upon it.

"I don't know what their procedures are but something is very lax."

'Got to stop'

Angela Hopkins, health board executive director of nursing, midwifery and patient services, said: "The health board recognises that some of the care given was below the standard that should have been provided to the patient and family.

"We fully accept the recommendations in the report and have taken action to address each one made.

"We are reviewing our appointment system and process and gastroenterology care pathways to provide an improved and more robust safe service for patients.

"We are also making sure that safeguard measures are implemented to improve our standards of engagement with patients while they are treated by the health service in north Wales."

The ombudsman also recommended that £5,000 be paid to the family to acknowledge the "failings and provide financial redress" along with £500 for its "poor complaint handling".

The report said the family wanted changes to ensure the same "mistakes are never repeated".

The ombudsman can hold the institution to account but not individuals involved in the care of Mr Nolan.

Hs mother has written to the General Medical Council which regulates doctors and the medical profession asking that her son's case is reviewed.

"As far as I can see they seem to be above the law and not answerable to anybody and it has got to stop," she said.