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Significant failings by hospital staff.


Significant failings by hospital staff led to unnecessary suffering for a cancer patient before her death, a Public Services Ombudsman report concluded.

Ann Jones, 69, of Rhyl, died in August 2019, with bowel cancer but the ombudsman found that complications after surgery were not properly identified and weight loss was blamed on psychological factors, rather than the pain of a bowel obstruction.

The report, which refers to Ann Jones as ‘Mrs M’, said it was impossible to know if she could have been saved if she had been correctly diagnosed.

It said: "The uncertainty surrounding whether an opportunity to surgically intervene was lost and was an injustice to Mrs M and her family.

"These failings impacted upon her human rights in terms of her dignity but also her quality of life. There was also an impact on the patient's family's rights in terms of witnessing her debilitating decline."

Ann Jones’ daughter Charlotte Finlay said: "The most relevant part is that she shouldn't have suffered for eight to nine months with that pain. There should've been more done."

Mrs Jones underwent colon surgery in February 2019 at Glan Clwyd Hospital in Bodelwyddan, Denbighshire.

She returned home but was readmitted in May before being transferred to Llandudno Community Hospital.

She went home again in July, only to return to Glan Clwyd Hospital on 3 August but by then she was deemed too unwell to survive surgery and died on 24 August of acute peritonitis - inflammation caused by an infection.

Ms Finley added: "She had scans as early as March and the results show that she had a blockage of her bowel when she could've been strong enough to be given the chance for an operation. As a family that'll never leave us, that question of 'would she be here if she would've been operated on in March?'"

Public services ombudsman, Nick Bennett, said: "This tragic case involved an alarming, systemic misdiagnosis. Numerous significant failings and deficiencies took place before, during and after Mrs M's discharge from hospital."

Denbighshire council was also criticised for the inadequate home care support offered to Mrs Jones when she was discharged from hospital.

A further complaint that both the health board and council failed to issue a co-ordinated response to the family after Mrs Jones died was also upheld.

The report recommended both organisations apologise to Mrs Jones' family, that the health board paid £5,000 for the distress caused, and staff were given feedback and training to learn lessons from what happened.

Deputy chief executive of Betsi Cadwaladr University Health Board, Gill Harris, said: "We sincerely apologise for the failures in care and for the way the subsequent complaint was handled. We accept the findings and recommendations in full and are currently working with the relevant clinical teams to implement the necessary improvements."

Denbighshire council said it was "sincerely sorry" for the distress caused to the family and had issued a written apology to her husband.

A council official added: "The council fully accepts the findings and recommendations made in this report and we are making sure these are implemented with the relevant staff and departments involved."