THE case of a man who died at the Royal Gwent Hospital three days after his admission in December 2014 is an example of an "appalling lack of weekend care", the Public Services Ombudsman for Wales has concluded.

The man - referred to as Mr Y in the Ombudsman Nick Bennett's report, published today - was admitted to the hospital on Friday December 5 2014, suffering from severe constipation. He died three days later.

His daughter, referred to as Mrs X, complained to the Ombudsman about his care from his  admission and over the following weekend.

She complained that her father’s raised blood glucose levels were not managed and he was not seen by a doctor for several hours.

She said that despite her father having a full care package in place at home, he remained on an unsuitable ward and had an undignified end of life.

She also complained that Aneurin Bevan University Health Board’s investigation of her complaint had been unhelpful.

Following an investigation, Mr Bennett upheld Mrs X’s complaints.

He found that no action was taken in relation to Mr Y’s elevated blood glucose levels over the weekend, and nursing staff had not informed the medical team of Mr Y’s "aspiration or fluctuating swallowing ability (dysphagia)."

He was not referred to a Speech and Language Therapist and he had not been kept as a 'nil by mouth' patient in the interim.

The Ombudsman found that on Sunday December 7 2014, Mr Y’s condition deteriorated, but he was not reviewed by a doctor for more than six hours.

Nursing staff did not escalate the failure of a doctor to attend Mr Y, and as a consequence, antibiotics were not administered in a timely manner.

Mr Bennett could not be certain whether earlier intervention might have led to a different outcome for Mr Y.

But the health board had not recognised that Mr Y had a full care package in place at home, and he had been placed on an inappropriate ward. 

The Ombudsman did not uphold Mrs X’s complaint about her father’s end of life taking place on an open ward, as side rooms were in use by patients with priority need.

But he did find that the health board’s own investigation of Mrs X’s complaint did not identify the failings in her father's care. 

The health board has subsequently agreed to apologise to Mrs X for the identified failings and will pay her "financial redress" of £2,000, in recognition of the distress and uncertainty associated with her father’s care.

All nursing staff will be reminded that patients with dysphagia should be referred without delay to a speech and language therapist, and be kept 'nil by mouth' until they have been formally assessed.

There will be a review, with educational diabetic nurse input, into whether there are training issues for nursing staff on the ward, in relation to identification and management of hyperglycaemia.

The review will also seek to establish why escalation procedures were not followed in this case.

The escalation process will also be reviewed, in light of the outcome, to ensure it will be more effective in the future.

A spokesman for Aneurin Bevan University Health Board said: “Our thoughts remain with the family of Mr Y and we are writing to them to unreservedly apologise for the failings identified in the Ombudsman for Wales Report.

“We accept the report’s findings and its recommendations. We have processes and procedures in place to monitor our patients’ blood glucose levels, to manage dysphagia and to ensure patients are seen by a doctor within appropriate timescales.

"However, on this occasion we recognise that our care for Mr Y fell below the high standards we expect.

“We are finalising a detailed action plan which sets out the further actions that will be undertaken to meet the recommendations outlined in the report, which include reminding our staff of appropriate processes and escalation procedures and addressing any further training needs amongst nursing staff.

"The implementation of these actions will be monitored and shared with Welsh Government to identify the improvements in care and services we provide to our patients as a result.

“We are committed to learning from concerns raised about our services to further improve the care we offer to our patients and we deeply regret the failings in the care of Mr Y.”