In this month’s edition of the Ombudsman’s findings, we highlight our recent investigation reports.
This month we published decision reports from 17 complaints investigated by the Ombudsman. Fourteen of these were about health services, one about a housing association and two about local government. The outcome of these 17 complaints were
• Fully upheld: 9
• Some upheld: 5
• Not upheld: 3
We made 45 recommendations to public bodies.
Our published decision reports can be read on our website.
Investigation reports
This month we published two investigation reports about the health sector. In these cases, we have made significant findings and laid a detailed report before Parliament. We publish these so that others can learn from the findings to prevent similar outcomes in the future.
202307762
We found that a health board failed to provide reasonable care and treatment to a patient who suffered a bleed in the brain.
The board failed to perform an MRI scan before discharging the patient, who had a severe headache, and did not follow the advice of the neurosurgical team. They were readmitted the next day and died following a long hospital admission.
We made five recommendations to the board. We asked them to apologise to the patient’s family, review their current systems and monitor awareness and compliance of the relevant guidelines.
202307063
We found that a health board failed to provide reasonable nursing care (both at home and in hospital) to a patient with multiple sclerosis.
The patient, who was immobile and doubly incontinent, developed pressure damage to their skin and was later admitted to hospital with sepsis. They were discharged but readmitted shortly after and died during their admission.
We found that the district nursing team failed to update assessments accurately and did not appropriately check the patient’s skin during home visits. While in hospital, the nursing team did not provide reasonable end-of-life care or follow a person-centred care plan.
We made ten recommendations to the board. We asked them to apologise to the patient’s family and conduct an independent audit of both inpatient and district nursing care.
Our published investigation reports can be read on our website.