A PATIENT with learning disabilities was "failed" by Betsi Cadwaladr University Health Board, according to a new report. 

The report issued by Public Services Ombudsman for Wales found failings in nursing care for Ms A, an adult with learning disabilities.

The Ombudsman launched an investigation after Ms D complained about the care and treatment her sister, Ms A, received from Wrexham Maelor Hospital in July 2022.

In addition to failing to monitor and manage Ms A’s pain and epilepsy, Betsi Cadwaladr University Health Board also failed to communicate with her and support her personal care needs, nutrition and hydration.

Ms A had several medical conditions, including epilepsy, cerebral palsy and learning disabilities. She lived in a nursing home, had limited communication, and required 24 hour care and support.

The Ombudsman found care provided to Ms A "fell short of acceptable standards", with concerns being raised over care needs, medication administration, record keeping and handling of intial complaints.

Public Services Ombudsman for Wales, Michelle Morris, said: “The evidence I have found shows that Ms A was at times in pain, which was not only distressing for her, but for her family as well.

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"It concerns me that Ms A would likely have been very frightened when alone in hospital without family present, and experiencing pain. Additionally, the lack of record keeping in relation to Ms A’s seizures is not only dangerous, but also represents a poor level of care.

"I upheld this complaint as I consider these shortcomings represent a serious service failure. The standard of care Ms A received fell very short of the required standard.

"The Equality Act requires healthcare providers to make reasonable adjustments for disabled people to ensure they are not disadvantaged when accessing healthcare. This did not happen in Ms A’s case, and she received a poor standard of care because of her learning disabilities.”

The Ombudsman made several recommendations to the Health Board, including:

  • Implementing a regular ward audit of nursing documentation, to include care plans and seizure charts.
  • Providing training to ward staff in respect of mental capacity and best interest decision making.
  • Engaging with the social services departments of all local authorities within the Health Board’s area to implement a joint care pathway to ensure safe staffing levels when vulnerable people with additional needs are admitted from care/nursing homes.
  • Providing confirmation that its Patient Safety and Experience Committee will monitor compliance with ongoing actions to satisfy the Ombudsman’s recommendations.

Betsi Cadwaladr University Health Board (BCUHB) has accepted the Ombudsman’s findings and conclusions and has agreed to implement these recommendations.

Dr Chris Stockport, Executive Director of Transformation and Strategic Planning for BCUHB said: “I sincerely apologise to Ms A and D, on behalf of the Health Board, and we will also be writing a direct letter of apology for the failings in the care we provided and how the complaint was handled.

“Ms A’s care fell below the standard we expect, and we accept all of the Ombudsman's recommendations.

"While we welcome the Ombudsman's acknowledgement of the progress we have made so far, we know there is more to do and we are taking further action to improve services and the standard of care and treatment we provide.”