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Cefn Coed Hospital patient let down, says Wales's ombudsman

By South Wales Evening Post  |  Posted: February 15, 2013

Cefn Coed Hospital

Comments (7)

A HORRIFIED family took photos of the gangrenous pressure sore their ailing relative developed in hospital and showed them to medics.

The 77-year-old had been assessed as being at risk of pressure sores when he was first admitted to Swansea's Cefn Coed Hospital.

He was not re-assessed until after he had developed the buttock wounds two months later.

It was one of three failings identified by the Public Services Ombudsman for Wales in the care of the pensioner, who was admitted to Cefn Coed in November 2009 and died there four months later.

Abertawe Bro Morgannwg University (ABMU) Health Board, which runs the Cockett hospital, has apologised.

The other two failings concerned insufficient pain management and nutritional assessment.

Around a month before his death the patient, referred to as Mr O, had become unwell.

Three days later he was left in a chair all day long. That night, according to ombudsman Peter Tyndall, staff noticed that his "buttocks have started to break down and look very sore".

Referring to the failure to reassess Mr O's bed sore risk, he said: "Pressure sore assessment is a basic part of nursing care and it is difficult to understand how it was overlooked, more so as Mr O was already known to be at risk.

"Further, Mr O became unwell from February 11, increasing his susceptibility to pressure damage, and still no assessment was done. This was simply unacceptable, and was, as the nurse adviser has said, a serious failing."

Mr Tyndall said he had been shocked at the pressure sore photos, but judged the sore had then been properly managed.

Mr Tyndall did not accept a contention that food and water had been withheld from the patient, who suffered dementia and was believed to have had a stroke.

But he said Mr O was not referred to a dietician as he should have been, nor was his ability to swallow assessed.

"That referral should have happened and did not," said Mr Tyndall. "The health board has offered no explanation as to why."

Although Mr O's pain relief dosage was increased as the weeks passed, Mr Tyndall concluded that "it seems likely that his pain management was insufficient on occasions".

The ombudsman also criticised the ABMU-led review of the case.

He said: "In my view, the (ABMU) report simply offered up the views of the clinicians; there was no proper analysis of the care provided. It appeared to defend the actions of the health board, which is not its function."

Mr Tyndall has referred his findings to Healthcare Inspectorate Wales due to similar cases in 2011 and 2008 involving ABMU.

He also suggested ABMU pay Mr O's family £2,000 compensation.

An ABMU spokeswoman apologised to the family and acknowledged "shortcomings in important aspects of care this patient received, which fell well below the high standards expected."

She said no Cefn Coed inpatient had developed a pressure sore since September 2010, when a new initiative was implemented.

She said ABMU's hospitals now had "some of the lowest rates of pressure ulcers in the world".

The spokeswoman added: "The end of life care pathway used in 2010 is no longer used by the health board.

"We also have better mechanisms in place to assess and serve patients' nutritional needs.

"ABMU health board strives to continually improve the care and services we are able to provide for them, and to learn lessons when we do get it wrong."

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  • jampy3  |  February 15 2013, 10:23PM

    So why did it have to go to the ombudsman???? Why didn't Investigation And redress deal with the situation??? Is it beacause as in my case the body set up do deal with these complaints when they are reported, are afraiad to challenge clinicians? you bet they are||

  • clarysage50  |  February 15 2013, 6:45PM

    .' EMI wards are all too often used as dumping places for tiresome relatives' I object strongly to this statement - I have a relative in an EMI unit at the moment. She is 92 years of age and it was the NHS which placed her in the unit because it was necessary and appropriate for her care and well being. She was NOT 'dumped'. Unfortunately, you seem to know little about this form of care......my relative has deteriorated from being a fully functioning person into someone who does not know her family or,indeed, where she is at any given moment. Perhaps you might like to think for a moment as to what this is like - to see a loved family member not knowing who you are??? So, please stop and think before making such crass, 'off the cuff' statements and take some time to actually find out what EMI units do for the many sad, unfortunate, much loved family members who stay in them.

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  • ABM_Health  |  February 15 2013, 3:34PM

    The Ombudsman's Report was quite right to criticise us - the standard of care was well below what was expected. We gave a longer statement than there was room to print. Here is is in full: Response to Ombudsman's report We would like once again to offer our most sincere condolences to the family of this patient for their sad loss; and to apologise for the shortcomings in important aspects of care this patient received, which we acknowledge fell well below the high standards expected. We would like to give assurances that there have been major changes since the time this patient was an inpatient at Cefn Coed Hospital, particularly around pressure ulcer prevention. Today, our hospitals have some of the lowest rates of pressure ulcers in the world. In 2008 pressure ulcer incident rates stood at 13% (over 400 incidences a month), which was typical for the NHS but by December of 2012, the rate had decreased to less than 1% (just 2 incidences across 2300 beds during the whole month of December). Pressure sores are not acceptable, and in almost all cases they are avoidable. Our clinicians have been determined to find ways to greatly reduce the risk of patients developing pressure ulcers, and in 2008 we began a major programme developing interventions to prevent pressure ulcers. We successfully piloted this early work in 2009, in a small number of acute wards. As our staff underwent training, we were then able to steadily roll out these interventions, known as the SKIN bundle, across ABMU. They are now in use at all our hospitals, where nine wards have prevented patients developing any pressure ulcers for over three years; and a further seven wards have stopped pressure ulcers for over two years. We are currently working with nursing homes, and starting to work with residential homes, to spread this good practice further. Sadly, at the time this patient was in Cefn Coed Hospital, the SKIN bundle had not yet been rolled out to that hospital. It was implemented at Cefn Coed Hospital in September 2010, and since then there has not been a single incident of an inpatient using the ward (which has since transferred to a new facility) developing a pressure ulcer. In response to other concerns raised in the Ombudsman's report; the physical ward this patient was in is no longer in use. It was replaced in 2012 by new wards in Ysbryd y Coed, a new £18 million unit in the grounds of Cefn Coed Hospital, which was purpose built and designed for patients with dementia. The end of life care pathway used in 2010 is no longer used by the Health Board. We now follow the All Wales Integrated Care Priorities for the Last Days of Life, and this is monitored regularly by doctors. We also have better mechanisms in place to assess and serve patients' nutritional needs. In addition, we have introduced a quality and safety system into mental health services which closely monitors the standards of care on wards, including nutrition; infection control, adherence to the SKIN bundle and training and education, among others. We realise that elderly people are among the most vulnerable patients in our care. ABMU Health Board strives to continually improve the care and services we are able to provide for them, and to learn lessons when we get it wrong. If anyone wants to find out more about the work we've been doing around pressure ulcer prevention, here's a link to our webpage: http://tinyurl.com/b8hwtwq

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  • weslangdon  |  February 15 2013, 2:56PM

    I was trying to argue that responsibility here was wider than just the hospital and included the GP and the family. EMI wards are all too often used as dumping places for tiresome relatives. Pertinent questions from the reporter would have been how many patients on the ward how many staff on duty etc. Its my view that if there any blame in a complex organisation it is invariably poor management

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  • Dan01  |  February 15 2013, 2:07PM

    Didn't realise that s l a g g i n g was a naughty word!!

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  • Dan01  |  February 15 2013, 2:06PM

    Fair comments there weslangdon. ****ging off the NHS is the nations No 1 pastime currently, even ahead of the bankers! There is much wrong with our NHS, but there is far more which is right which is taken for granted.

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  • weslangdon  |  February 15 2013, 11:04AM

    Two questions, who arranged for the elderly mans admission into the hospital... [a GP perhaps how did they follow up the referral], and how often did the family visit him? This article and others this week from the SWEP are part of an on going campaign by the Daily Mail group to vilify the NHS. The NHS is a huge organisation and has shortcomings but we as individuals need to be more involved in the treatment we receive and for that of close relatives but relentless sniping is undeserved. The message though from the SWEP though is always criticism where it should in general terms be praise