A cancer patient died without suitable end-of-life care following surgery, an ombudsman investigation has revealed.
Mrs W – the name has been anonymised – complained about the care provided to her husband Mr W by Abertawe Bro Morgannwg University Health Board following his oesophageal cancer surgery in 2018.
Mrs W said Mr W never really recovered after his surgery and he struggled to eat and became emaciated, immobile, incontinent and depressed. Although palliative support was eventually arranged this was only arranged two weeks before Mr W died.
Consequently relevant palliative care aids such as a commode and a hospital bed were still in the process of being delivered and installed and Mr W never had the benefit of them.
Mrs W said witnessing her husband’s slow deterioration and death as his sole carer and without advice or support left her with feelings of pure terror and helplessness that would stay with her forever. She said she could not understand why Mr W was not given the help and support that he needed and deserved.
The ombudsman found there were communication failures around explaining diagnosis, prognosis, and likely outcomes to the patient and providing psychosocial support and specialist dietetic support before, during, and after his surgery.
The ombudsman concluded that there was no evidence the health board provided adequate and appropriate palliative post-discharge care and support to the patient and his family following his unsuccessful surgery and failed to deal with the requests from the patient’s family for contact and support promptly.
Swansea Bay and Cwm Taf Morgannwg Health Boards have agreed to several recommendations including a written apology for Mrs W and to implement compulsory training for all doctors and nurses treating and managing patients with gastro-intestinal cancer covering advanced communication skills and the need for patient involvement in care.
Public Services Ombudsman for Wales Nick Bennett said: “This is a deeply shocking case where a man has died without suitable end-of-life care and sadly I think that both Mr and Mrs W’s human rights are likely to have been compromised.
“Mr and Mrs W were not given the time to prepare for his eventual outcome both mentally and with suitable palliative care aids and support. This impacted on Mr W’s rights as an individual and on both his and Mrs W’s rights as part of wider family life.
“This is particularly important at the end of someone’s life and the failures identified therefore represent serious injustices to both Mr and Mrs W.
“The lack of support given to Mrs W has left her with unimaginable emotional pain and I can only hope my investigation brings her some small comfort.”
After the events leading to this complaint changes took place to NHS provision in the area. Swansea Bay and Cwm Taf Morgannwg agreed to implement the ombudsman’s recommendations.
A joint statement was provided in response to this case by Mark Hackett, chief executive at Swansea Bay University Health Board, and Cwm Taf Morgannwg University Health Board chief executive Paul Mears.
It stated: “Firstly we would like to take the opportunity to offer our sincere apologies to Mrs W and her family for the distress they experienced and to again convey our condolences on their very sad loss.
“We have accepted the ombudsman’s findings and agreed to implement the recommendations in full.
“Mrs W’s account of their experience is sobering and there are clearly areas in which the care we provided could have been significantly improved.
“It is evident the couple were not fully supported during Mr W’s deterioration and we sincerely regret that. It falls considerably short of the standard of care we expect all our patients to receive.
“Both health boards have carried out a full review of events to ensure action is taken to improve practice to prevent this happening again.
“In line with the recommendations we are taking steps to ensure that patients with such types of cancer have access to nutritional assessment and to specialist dietetic and psychosocial support.
“Clinicians in the service will be reminded of their obligations to have candid discussions with patients about their treatment and outcomes.
“Training will also be provided covering advanced communications skills and the need to involve patients in their own care.
“Additionally support will be provided to the specialist nurse to ensure all conversations with patients are recorded within their medical notes.
“We are also arranging staff training to ensure human rights are always considered when providing care to patients and when patients or family members raise concerns about the care and treatment provided.”