Ysbyty Gwynedd patient died after 'substandard' care

Ombudsman Nick Bennett: 'I urge the health board to learn from this case'

Medical staff missed opportunities which may have prevented a hospital patient's deterioration and subsequent death, a watchdog has found.

The man, identified only as "Mr D", received "substandard" care at Ysbyty Gwynedd, Bangor.

Public Services Ombudsman for Wales, Nick Bennett, said Mr D had respiratory failure and should have been moved to a high dependency unit.

Betsi Cadwaladr University Health Board has apologised to the family.

The complaint was raised by the man's daughter who worked for the health board.

Mr D, who was admitted to hospital in December 2014, suffered from chronic obstructive pulmonary disease (COPD) and was diagnosed with pneumonia and respiratory failure.

A day later his daughter was informed that Mr D was improving and discharge plans were discussed.

'Serious clinical failings'

But his condition worsened over the next 24 hours and on Christmas Day, four days after admission, Mr D suffered a cardiac arrest and died.

His daughter complained to the health board in February 2015.

But it was not until 19 months later that officials replied and, while they admitted failing to carry out key observations, they claimed these did not affect the "sad outcome", the ombudsman said.

Mr Bennett found a number of "serious failings" including:

• Missed opportunities to take action which may have prevented Mr D's deterioration and subsequent death

• Inaccurate recording of the cause of Mr D's death

• Failure to carry out a serious incident report despite this being referred to in the complaint response

Mr Bennett said: "I urge the health board to learn from this case and address the serious clinical failings.

"By doing so, I hope that patients requiring critical care will not be overlooked in the future."

Health board nursing executive director Gill Harris said: "We are deeply sorry for the additional distress we have caused the family, at an already difficult time, by the time it has taken us to respond to these concerns.

"We apologise that we did not deliver the standard of care that we should have and for the unacceptable delay in responding to the family's complaint.

"We are working hard to improve our concerns process to make sure we provide meaningful responses in a timely manner."

She added the ombudsman's recommendations would be implemented and a progress report will be made in three months.