Betsi Cadwaladr: Vulnerable woman, 60, died day after doctors missed new symptoms, report finds
The care of hospital patient treated at Ysbyty Glan Clwyd was "compromised" after she was sent home from hospital days before she died, a report has found.
The Ombudsman found "care failings" caused the 60-year-old woman, "avoidable" and "unnecessary pain" before her death.
Ms B, the patient, was admitted to hospital in May 2020 with breathing problems.
She had long-standing health conditions and needed regular care by nursing teams.
However, there were no "skilled staff" available to treat her and nurses did not tell doctors that Ms B had been helped.
Ms B then developed new symptoms, which suggested a bowel blockage. She was discharged without these symptoms being considered on 5 May, according to the Ombudsman.
Ms B, a wheelchair user, was admitted to hospital the following day when her carers found her unwell.
She was assessed and treated for possible sepsis together with heart-related issues and died later that afternoon.
The ombudsman's findings come after another recent report found significant delays in patients receiving care in the hospital's emergency department.
Shortages of staff, high numbers of seriously unwell patients and a lack of space to treat them in were all raised as significant issues at the hospital.
Mrs A, the patient's sister, complained to the Betsi Cadwaladr University Health Board about the failings, but was unhappy with the response.
The health board was recently placed back into special measures for the second time following "serious concerns about performance, leadership and culture".
The Ombudsman described the health board's initial review as lacking "depth, rigour, openness and transparency".
Michelle Morris, Public Services Ombudsman for Wales, added that she was "very concerned" that "similar problems of failings in basic nursing care, in record keeping, and in communication in previous cases," have been investigated at Ysbyty Glan Clwyd.
Dr Nick Lyons, Betsi Cadwaladr University Health Board’s interim deputy CEO and executive medical director, said: “I would like to sincerely apologise again to this patient’s family for the distress caused both during her treatment and the period of their complaint.
“We acknowledge the Ombudsman’s report, accept all the recommendations in full and have made sure the lessons contained within it have been made clear to all staff involved.
“We can only gain the trust of the public we serve by being completely transparent about failings when they occur - and we are fully committed to that principle.”