Patient's care at Swansea's Morriston Hospital 'abject'
A patient with severe learning difficulties who died in hospital may have survived if he had received better care, a watchdog has found.
Paul Ridd's nursing care at Morriston Hospital in Swansea was called "abject" and "dire" by the Public Services Ombudsman for Wales.
Mr Ridd, 53, died of respiratory issues after transfer from intensive care.
His family welcomed the report. Managers said procedures had been improved.
Awareness training for all doctors and nurses has been ordered at the hospital.
The ABM University Health Board, which runs the hospital, also said it had already started implementing the recommendations made in Peter Tyndall's report.
Mr Ridd, from Baglan near Neath, had severe learning difficulties as a result of brain damage at birth.
He was admitted to Morriston Hospital on 31 December 2008 with a serious bowel problem and underwent surgery.
But following his death on 23 January 2009 his brother and sister complained about many aspects of the way he was looked after.
In particular they were concerned he contracted pneumonia while in intensive care and was transferred prematurely to a general ward, where they said his care was poor in the days before he died of respiratory problems.
His brother Jonathan Ridd said: "When Paul was in the intensive care unit, he had top quality care, like a five star hotel, and when he was moved across the corridor, it felt like we were in a Third World country in terms of care, cleanliness.
"There was no leadership and his observations were not done as instructed."
Mr Ridd said in the last four hours of his life, his brother's carer was "constantly begging" the nursing and medical staff to examine him as his condition had steadily deteriorated.
In a report published on Wednesday, Mr Tyndall said concerns about Mr Ridd's condition after he was transferred to the general ward were raised with staff.
But among his findings were:
- A failure of supervision
- Inadequate examinations by doctors
- A failure to ensure Mr Ridd's care complied with the Disability Discrimination Act.
"Nursing care on the ward was abject," said Mr Tyndall.
"It greatly concerns me that the dire level of nursing care to which [Mr Ridd] was subjected on the ward, could have happened in the 21st Century.
"It is vital that change is robust and long lasting.
"I consider it vital that nursing and clinical care providers respond appropriately to the challenge that patients with learning disabilities present. This did not happen."
Wayne Crocker, director of the learning disability charity Mencap Cymru, said the case should be a "wake-up call" for health professionals in Wales.
"It's a disgrace that someone can go into a hospital, a place where they should be looked after, and see their chances of survival reduced because they have a learning disability," he said.
"Currently, people with a learning disability get sub-standard healthcare compared to those without - it's as simple as that."
The ABM University Health Board said it investigated and identified shortcomings following Mr Ridd's death and swiftly took action to make improvements.
These included increasing the number of nursing staff, appointing a new ward sister and ensuring staff completed an education and training programme.
It said procedures had also been tightened and improved in all its hospitals.
"As a result we want to assure the public that the ward today has improved significantly from the way it was over two years ago," it said.
"We can also give assurances that we have used the experience of this tragic event to improve our practices across the health board.
"Whilst we fully recognise that this can be of little comfort to the family it is important that they know that the concerns that they have raised have improved care for others.
"We would wish to reiterate our sincere apologies to them for failing to meet the needs of this patient."
His sister Jane Nicholls told BBC Wales: "Paul couldn't communicate like you or I can, so you had to pick up on the signs.
"I find it really difficult because I don't know quite how Paul felt and he died from excess secretions in his upper airways, which is like drowning, and he was unable to communicate to us."