Woman’s ‘deplorable’ death raises questions about care
2:20pm Friday 4th January 2013 in News
THE case of a woman who died in circumstances her daughter described as “deplorable, unforgivable and a complete circus” raises Wales-wide issues over care, says the Public Services Ombudsman.
Peter Tyndall criticised Aneurin Bevan Health Board, a care home, and Wales’ care and social services watchdog for case failings.
He says contract arrangements between health boards and independent care homes must be tightened.
The names of the woman who died, her daughter who made the complaint and the care home, are withheld in his case report.
The woman died in hospital in January 2010, her daughter’s aforementioned descriptions in the report of her final days relating to the care home’s failure to follow their wishes on end-oflife care.
As the woman’s health deteriorated, her daughter outlined the end-of-life care plan to staff.
They intended that she be taken to hospital on GP advice.
The woman, who had vascular dementia, diabetes and a history of strokes, wished to remain at the home but there was no documented end-of-life care plan, a serious failing according to Mr Tyndall’s report.
Hospital doctors said she could be discharged, but this did not happen because the district nurse was not trained in certain required procedures.
Confusion and uncertainty about whether the woman could return to the care home for palliative care resulted in her daughter “missing out on spending quality time with her mother in her final hours,” states the report.
It also highlights concerns about her care at the home from April 2009, including “ineffective” care contract monitoring, initially by Monmouthshire Local Health Board, succeeded by Aneurin Bevan Health Board in October 2009. There were issues over bathing, vegetarian diet requirements and a failure to tell her daughter about injuries the woman sustained at the home.
After she died, her daughter complained to the home, health board and the Care and Social Services Inspectorate for Wales (CSSIW), but was not satisfied with the processes, the time taken, and the answers given.
He said care provided on the health board’s behalf failed to meet expectations, contract provisions relating to complaints handling did not meetNHS requirements and CSSIW investigation and compliance processes were too narrow and insufficiently robust.
‘Patients must be informed’
HEALTH boards commissioning care from independent providers must satisfy themselves appropriate standards are in place and in contracts, said Mr Tyndall. They must also ensure NHS-based complaints procedures are included.
“Patients must be informed of their right to complain. I am not satisfied this is the case at present,” states Mr Tyndall.
He met health board chief executive Dr Andrew Goodall, and wants to meet Welsh Government officials and other health board bosses to ensure contracts with independent providers are revised.
Among 13 recommendations is the woman’s daughter be paid £750 by the board and CSSIW.
The board accepts the findings and offered apologies for the failings identified, said Dr Goodall.
“The health board is aware some matters relate to a period up to and including October 2009, prior to the establishment of Aneurin Bevan Health Board. Soon after its establishment, the health board recognised the issues covered in the report and has responded,” he said.