A woman’s death from sepsis could have prevented, the Public Services Ombudsman for Wales has ruled, after a complaint was made to Betsi Cadwaladr Health Board.
The Ombudsman launched an investigation after a woman - referred to as Mrs L - complained about the care and treatment her late mother, - referred to as Mrs K - received from Betsi Cadwaladr University Health Board between January 2021 and her death on 31 January 2022 from biliary sepsis.
The Ombudsman concluded that if Mrs K had been treated appropriately at the outset, her pancreatitis would have been treated successfully and her deterioration and death may have been prevented.
The Ombudsman also found little to no evidence that the seriousness of Mrs K’s condition was appropriately communicated in October to her and her family either before or after treatment.
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Public Services Ombudsman for Wales, Michelle Morris, said: “The failure to identify Mrs K’s gallstones in January 2021 was an unacceptable service failure which caused Mrs K and her family a continued and grave injustice.
“I am saddened to conclude that, had Mrs K been treated appropriately at the outset, her acute pancreatitis would have been treated successfully and on balance, her deterioration and death might have been prevented.
“I am deeply concerned at the Health Board’s seeming lack of candour in its complaint response to Mrs L, and its lack of objective reflection by its clinicians during my investigation in that it continued to fail to identify and acknowledge failings in Mrs K’s care.
“I am mindful that the episode of care happened during a time when there were still some restrictions in place as a result of the Covid-19 pandemic.
“However, having taken full account of the potential impact of those restrictions, I have been that reassured that, even with the Covid-19 restrictions on endoscopy services, Mrs K would have accessed appropriate treatment within a few weeks.”
The Ombudsman recommended that the health board “provide Mrs L with a full apology from the Chief Executive”, pay her £4,000, and review the case and report on its findings. The health board agreed to implement the recommendations.