Kidney patient faced a series of mistakes


Staff reporter (Denbighshire Free)

A HEALTH board has been told to pay £2,750 to a young kidney patient who was left in discomfort because of a “catalogue of errors” in her care.

The Public Services Ombudsman for Wales has upheld a complaint from the woman, identified only as Miss X, who faced a long wait for an operation and was then left in further distress when a stent was eventually removed and clinicians were unaware it had not worked.

The Betsi Cadwaladr University Health Board has apologised to the woman and acknowledged that the repeated postponements of the pyeloplaty surgery – the removal of a blockage where the kidney is drained – were totally unacceptable.

The woman was first referred to a urologist by her GP in December 2011 and she met a consultant the following month, when an obstruction was identified.

An urgent operation was called for but by July Miss X’s GP asked for it to be brought forward as her nausea was getting worse and she was losing weight. After further delays the GP wrote again and the operation was eventually carried out in May 2013, when a stent was inserted to allow the kidney to drain.

The stent should have been removed six weeks later but an administrative error led to it not being done until October.

Miss X’s kidney failed almost immediately and she believed the delay may have contributed to the problem. 

By July 2014, she was still awaiting a review consultation and finally received an appointment in January 2015, following which a stent was inserted into her right kidney. 

In her complaint Miss X said she had been in pain every day, was sick and had lost weight.

She also claimed there was a risk of her good kidney failing because it was being overworked.

The health board apologised for the initial delays and for the fact that she had not been called back for a review, which was described as “an oversight”.

They said her case had highlighted a number of areas where the board’s systems and processes had failed and resulted in worry, confusion and delays for Miss X.

The Ombudsman’s professional adviser said the evidence suggested that the practice in the department was “inefficient and dysfunctional”.

He said a 15-month wait for a renogram – the review scan – was not reasonable and as it showed that the obstruction was unresolved it had left Miss X in discomfort.

The adviser said there appeared to be very little liaison between in-patient care and outpatient services and he was also concerned that neither clinical nor administrative staff appeared to accept responsibility for the shortcomings.

It was possible, but not definite, he added, that the further delays had led to further damage to the right kidney. 

In upholding the complaint, Natalie Cooper, the Ombudsman’s investigation and improvement officer, said Miss X had clearly suffered in injustice.

“The chronology demonstrates a catalogue of errors in this young person’s care,” she said. 

“It is unacceptable that ‘urgent’ appointments and ‘urgent’ surgery took so long to be actioned.”

She recommended that the board pay Miss X £2,500 for the additional discomfort and distress she suffered and £250 for the time and trouble incurred in pursuing her complaint.

It is also recommended that an audit system for managing clinic and operating bookings be carried out, that there be a review of the administrative support within the urology department and that a clear procedure be established to escalate individual cases where significant delays have occurred. 

Since receiving the Ombudsman’s report, the health board has agreed to act on all the recommendations.

See full story in the Free Press

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