Health board apology for Ystrad Mynach patient failings
A health board has apologised to the family of a woman of 58 who died in Ystrad Mynach Hospital in south Wales two years ago.
An official report by the ombudsman said there were significant clinical failings in Yvonne Furber's treatment.
It found examinations were not thorough enough and earlier detection of deep vein thrombosis could have prevented her death.
Aneurin Bevan Health Board said they had learned lessons from the case.
During her stay at Ystrad Mynach in February 2009, Ms Furber began to feel unwell.
But despite several requests by her family, nurses refused to transfer the woman to a medical ward or call an emergency doctor as it was during a weekend.
She later died of a heart attack, caused by deep vein thrombosis.
That condition had not been spotted, and the public services ombudsman report says that earlier detection could have prevented a death, and that examinations were not thorough enough.
Ms Furber had been admitted to the hospital with early onset of Alzheimer's disease but was physically fit.
She had been diagnosed with the disease in 2004 at the age of 54.
Grant Robinson, medical director of the Aneurin Bevan Health Board, told BBC Wales: "The first thing we'd like to do is we apologise and to say we fully accept the recommendations the ombudsman has made and we have taken action to address them.
"We aim to deliver health care of the highest possible quality but when things do go wrong we can learn from that and we're certainly aiming to learn lessons from this case."
Speaking on BBC Radio Wales, the public services ombudsman Peter Tyndall said a series of things went wrong.
"The complaint covers both poor treatment in the course of the admission for dementia, but also then a failure to diagnose DVT (deep vein thrombosis), which ultimately led to the patient's death."
Mr Tyndall said it was difficult to say how common these failures were because record keeping about what treatment patients received was so "poor".
Mr Tyndall said there was also a serious issues among the treatment of families.
He said Ms Furber's family had communicated "very effectively" with nursing staff at Ystrad Mynach Hospital, but their concerns were not reflected in the nursing notes.
"So clearly they were not being listened to," said Mr Tyndall.
"It's very clear the standard of care fell very far short of what it should have been, but it was compounded by a failure to diagnose a serious condition."
He said the hospital did not have proper procedures in place or arrangements for dealing with escalating medical conditions.
He has made a number of recommendations to correct failures at the hospital.