A PUBLIC Service Ombudsman report has revealed the health board that serves North Wales has made a “fulsome apology” for the “injustice” in care given to an elderly woman.

The case relates to the treatment of Jean Graves in 2013 who was receiving treatment on the Hergest Ward in Bangor’s Ysbyty Gwynedd. Her son made a complaint, only resolved last month, over her care and the health board’s response to those concerns.

Jean Graves spent nine weeks at Ysbyty Gwynedd’s Hergest unit in 2013 after struggling with anxiety and depression.

Her son said she was left “severely malnourished” and a watchdog said there were several failings in her care.

Mrs Graves’ son David Graves said his mother was not well when she arrived at the Bangor unit, but her condition deteriorated.

“In the nine weeks she was there, she suffered a series of what are termed SUIs, sudden untoward incidents,” he said.

Mr Graves said his mother – who was 78 when she was treated at the unit – collapsed six times and, over the course of six weeks, lost 25% of her body mass.

He added: “Her BMI at the point I witnessed her weighed was 14.5 and that was off the scale, under severely malnourished.”

For seven years, Mr Graves had raised concerns and complained about the way his mother was treated at the unit.

His mother died in 2016, aged 80.

The Ombudsman found failures in her care such as:

  • No overall comprehensive assessment to inform an overall care plan for Mrs Graves, while smaller plans were not goal orientated, nor focused on the outcome of any interventions
  • A fall risk assessment not being conducted for over a week after admission
  • A failure to complete a patient safety report regarding bruising found on the patient.

In addition to poor record-keeping in general surrounding the case, there was a failure to follow national guidelines for the prevention of malnutrition and no clear evidence that Mrs Graves’ nutritional needs were appropriately provided for.

As part of the settlement, the Chief Executive of Betsi Cadwaladr University Health Board (BCUHB) provided Mrs Graves’ son, David, with a “fulsome apology for the failings identified and the injustice” that was caused for him and his family.

The Health Board also paid an undisclosed amount in compensation “in recognition of the injustice caused as a result of the failings in the care and treatment provided” to Mrs Graves and “poor complaint handling and injustice” caused by this.

The Ombudsman report also stated that BCUB will review its guidelines on malnutrition screening, process for falls risk assessments, standards in care planning, process for reporting patient safety incident reports, and acting upon those reviews. It will also ensure that staff record incidents on its “incidents system”.

Mrs Graves will also be provided with an opportunity to engage with staff with responsibility for elderly patients’ dementia care in order to share learning from the complaints to improve future services.

Commenting, Welsh Conservative and Shadow Health Minister Russell George MS said:

“The findings of this report are staggering and shine the spotlight on significant failures inpatient safety and record-keeping.

“When people go to hospital, they are in an acutely vulnerable situation and deserve well-delivered and compassionate healthcare. The NHS exists and is paid for by patients and they expect better than this.

“It is only right that the Minister provides a statement in the coming days explaining why this case took so long to see justice and how people can have confidence that such cases will not arise again when we see them so regularly occur in North Wales.”

Commenting, Welsh Conservative and Shadow North Wales Minister Darren Millar MS added:

“This is a tragic case and the pain suffered by Mr Graves has been made all the worse as a result of the appalling way in which the concerns he has raised about his late mother’s care have been handled.

“The behaviour of the Betsi Cadwaladr University Health Board in this case has been appalling, records have been doctored and there have been failings in care which are inexcusable.

“We need an NHS in North Wales that is open and transparent and that learns from its mistakes; it’s clear from this report that we have a long way to go before that is the case.”