Cefn Coed Hospital, Swansea apology for patient failure
A health board has been referred to a watchdog after a highly critical report which found a hospital failed in caring for a 77-year-old man with dementia.
He died four months after being admitted to Cefn Coed psychiatric hospital in Swansea in 2009.
An ombudsman's report said the hospital failed to prevent pressure sores and did not provide sufficient pain relief.
Abertawe Bro Morgannwg Health Board, which was referred to Healthcare Inspectorate Wales (HIW), apologised.
Peter Tyndall, the public services ombudsman for Wales, identified "serious failings" in the care of the man, who is identified as Mr O in the report.
He said he referred the health board to the watchdog because two previous reports into the care of patients in other hospitals in the area had pointed to similar failings.
Health board statement
Abertawe Bro Morgannwg University (ABMU) health board says it has done a lot of work to cut the number of pressure sores suffered by its patients.
"Pressure sores are not acceptable, and in almost all cases they are avoidable," it said.
"Our clinicians have been determined to find ways to greatly reduce the risk of patients developing pressure ulcers, and in 2008 we began a major programme developing interventions to prevent pressure ulcers.
We successfully piloted this early work in 2009, in a small number of acute wards. As our staff underwent training, we were then able to steadily roll out these interventions, known as the SKIN bundle, across ABMU.
They are now in use at all our hospitals, where nine wards have prevented patients developing any pressure ulcers for over three years; and a further seven wards have stopped pressure ulcers for over two years.
We are currently working with nursing homes, and starting to work with residential homes, to spread this good practice further."
He said he hoped HIW would take his report into account in planning inspections.
The report found that Mr O was assessed as "at risk" of developing pressure sores, which are caused when pressure disrupts the flow of blood through the skin, causing ulcers.
The condition - also known as bed sores - is nearly always avoidable. But despite the risk, Mr O was not reassessed until after he developed a "significant" pressure sore two months later.
Mr Tyndall said that had assessment and further preventive measures been taken, it is possible that the sore might not have happened.
The report said that Mr O was not referred to a dietician and a speech and language therapist about his ability to swallow following a suspected mini-stroke while he was in the hospital.
It said it was likely that the provision of food and fluid to Mr O was "not as good as it could have been". It also found that his pain management was not "reasonable or consistent with guidelines".
"It therefore seemed likely that his pain management was insufficient on occasions," the report added.
The ombudsman ordered the health board to apologise and pay Mr O's daughter £2,000 for the distress its failings caused.
He said: "Cefn Coed hospital is due for closure [and] for the time that it remains open it should be expected to deliver the highest standards of care to those patients who continue to need its services."
The decision to close Cefn Coed was taken several years ago and it is being partially replaced by a new £18m unit. The hospital was deemed "not fit for purpose" by HIW last April.'Learn lessons'
The health board said it wanted to give assurances that there have been "major changes" since Mr O was an inpatient at the hospital, particularly around pressure ulcer prevention.
"Today, our hospitals have some of the lowest rates of pressure ulcers in the world," it said in a statement.
"In 2008 pressure ulcer incident rates stood at 13% (over 400 incidences a month), which was typical for the NHS but by December of 2012, the rate had decreased to [less than] 1% (just two incidences across 2,300 beds during the whole month of December)."
In response to the other concerns raised in the report, it said it had introduced a "quality and safety system" into mental health services which closely monitors the standards of care on wards, including nutrition infection control and training and education, among others.
"We realise that elderly people are among the most vulnerable patients in our care," the statement added.
"ABMU health board strives to continually improve the care and services we are able to provide for them, and to learn lessons when we get it wrong."