THE death of a 92-year-old man in a Gwent hospital last year - after Aneurin Bevan University Health Board failed to provide appropriate wound care following an operation - was a "heartbreaking injustice", a watchdog has concluded.

The pensioner - referred to as Mr R in an anonymised report by the Public Services Ombudsman for Wales - had a total hip replacement in an operation on September 14 last year, after falling at his home.

Six days later he was discharged to a community hospital for rehabilitation, but developed an infection in the wound that was not appropriately managed.

Despite being transferred back to the district general hospital, his condition worsened, and he developed hospital-acquired pneumonia and died on October 24 2017.

A complaint was made by Mr R’s son, who claimed that staff at the community hospital failed to identify, manage and treat his father’s post-operative infection or arrange for his transfer back to the district general hospital, for treatment, appropriately.

Public Services Ombudsman for Wales Nick Bennett found that:

• Appropriate dressings were not used at any time throughout Mr R’s care and at one-point telephone advice was given to use a stoma bag to collect the discharge, instead of making proper arrangements for wound care and using an appropriate dressing. Furthermore, Mr R’s wound clips remained in situ throughout his admission, which was likely to have exacerbated his infection.

• There was no comprehensive review of Mr R or his wound by a doctor after the initial admission assessment, despite clear evidence that infection was present.

• Senior medical advice should have been sought promptly from the district general hospital and the failure to do so delayed appropriate treatment for Mr R by at least a week, which made it more difficult to treat the infection, and for Mr R to fight it.

• The health board failed to ensure that it had fully informed the Welsh Ambulance Services NHS Trust of Mr R’s condition, so that appropriate transport could be arranged to transfer him back to the district general hospital.

“With regards to Mr R’s wound treatment, it’s deeply concerning that despite the patient’s son and nursing staff raising issues, both the doctor and a tissue viability nurse seemed to be unaware of appropriate best practice," said Mr Bennett.

“Had Mr R’s infection been successfully addressed, Mr R may not have developed the subsequent pneumonia which led to his death, and this is a heart-breaking injustice for the family of the patient.”

The health board has agreed to implement a number of recommendations arising out of the case, including issuing an apology and £2,000 to the patient's son Mr W in recognition of the service failures identified and the repercussions of those failings for Mr R.

A spokesman for Aneurin Bevan University Health Board said: “We unreservedly apologise for the failings identified in the Ombudsman for Wales Report and our thoughts remain with the family of Mr R.

“We accept the report’s findings and its recommendations including the financial compensation.

"Since this case was brought to our attention we have made the necessary improvements to ensure that this does not happen again and are finalising a detailed action plan which sets out the further actions we will take to meet the recommendations outlined in the Ombudsman’s report.

"The implementation of these actions will be monitored and shared with the Ombudsman.

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