NHS Complaints System: Wales — House of Commons, 2018-07-04
Topic: Health
Ann Clwyd (Labour, Centre-left): I am pleased to have the opportunity to talk about something that has been on my mind for a long time It is nearly six years since the death of my husband. Some Members will know that he spent his last two weeks on the respiratory ward at the University Hospital of Wales in Cardiff. He was admitted on Tuesday 9 October 2012 to what should have been a caring and safe place. Instead, what we found was the opposite. I left Owen in what I thought was a place of safety, thinking that the hospital could care for him better than we could at home. How wrong I was. Owen went into the hospital mobile, yet spent two weeks crammed in a bed, on a cold, uncaring ward Despite the poor care that Owen received, his condition initially settled. In fact, there were provisional plans for him to come home towards the middle of the second week. Sadly, his condition took a turn for the worse. In the early hours of Monday 22 October, I was advised that there was no reasonable chance of his surviving. He lost his final battle the next day. It was then that my battle began: the battle to find out what had happened to him and why Many Members will have heard of my concerns regarding the 27 hours he spent on a trolley in the A&E department. A later inquiry identified a number of nursing deficiencies. Sadly, my efforts to obtain information regarding his medical care have been met with considerable obstruction from the board of UHW Some time ago, I received help from an experienced NHS consultant, someone who has prepared numerous cases over a period of 30 years when there are allegations relating to clinical negligence. He said—we normally converse in Welsh: "Ann, roedd gofal Owen yn esgeulus. Hyd yn oed pe fyddai wedi goroesi ei salwch y tro hwn, byddem yn dal I deimlo fod ei ofal yn esgeulus. Yn esgeulus nid yn unig yn ôl safon 2012 ond yn ôl safon 1948, amser dechrau’r Gwasanaeth lechyd." That is, in his opinion, Owen’s care during his hospital stay was negligent. In fact, he said that even if Owen had survived his in-patient stay, his level of care would be considered unacceptable, not only by the standards in place in 2012 but by the standards in place at the inception of the NHS in 1948 My medical friend has pointed out his concerns. He was astonished to find that no doctor saw Owen on either weekend, no consultant saw him and no junior doctor saw him. I should point out that he was on a respiratory ward in Wales’s flagship teaching hospital. He was not in a convalescent ward; he was not recuperating from an acute illness. My late husband was an unwell man with MS, whose long-term disabilities had been made worse by what turned out to be pneumonia that he acquired at that hospital Most concerning, according to my medical friend, was the failure of the medical department to have any kind of effective handover arrangement, whereby the doctor going off duty would hand over all the clinical information to the doctor coming on duty. Formal handovers are far more important these days, as the shift systems of junior doctors means reduced hours. This means that over a weekend a patient may be seen by half a dozen different doctors, all working for the same firm Since continuing my inquiries about Owen’s care, I have learned a number of medical terms. I now know about a "low grade temperature" and that this may indicate that there is an infection somewhere, without the doctors being able to find out exactly where. I have also become familiar with the term "inflammatory markers". Inflammatory markers are blood tests that indicate the presence of infection. When the clinical markers change, and in particular when they increase, it suggests that there is an infection somewhere that is not under control. I will refer to just two One is known as the CRP—the C-reactive protein. The normal CRP is less than 10; Owen’s CRP was 22 on admission. Now, 22 is not particularly high, but it suggests that there may be an infection somewhere. Eight days later Owen’s CRP had crept up to 41. The fact that it was increasing—"going the wrong way" as the medics would put it—indicated that he could have an infection that could be going out of control. Owen’s neutrophil count—the type of white blood cell that increases during an infection—was also "going the wrong way". The normal is less than six. It was 8.7 on his admission—[Interruption.] Excuse me, Mr Speaker; I am sorry, but that is my phone.