A WOMAN who died on a hospital trolley after twice being moved to different hospitals against her family’s wishes had her human rights compromised.

The Public Services Ombudsman for Wales Nick Bennett also found that her dignity was not respected and the care she received in her final days was not considerate enough.

As a result he called for clinicians involved in the care of the woman, identified only as Mrs X, to undertake further training in end-of-life care.

He has upheld a complaint by Mrs X’s son – Mr Y – about the care she received from the Betsi Cadwaladr University Health Board and the background to the case is given in his first annual report on cases involving human rights or equality.

When Mrs X was admitted to hospital, the location of which is not identified, she was very ill and it was agreed between staff and her family that she should receive palliative care only for her comfort and quality of life.

Despite that, she was twice transferred to another hospital for a CT scan, but on the second occasion there was no bed available.

While waiting for a bed she died on a trolley, and Mr Y complained not only about her treatment but also that it took 17 months for the Health Board to respond to his complaint.

Mr Bennett found that Mrs X was unnecessarily transferred many miles even though a CT scan would not have altered the approach to her care.

“The Health Board’s approach was detrimental to Mrs X’s well-being and the manner of her death,” he said.

The decisions to transfer not only failed to take account of her individual needs but also her family’s wider needs.

Among the contributory factors identified were that no comprehensive assessment was made of Mrs X at her initial admission to A & E and she was not reviewed by a consultant for 11 days as no leave cover was in place.

The Health Board has accepted the Ombudsman’s conclusions and recommendations, and apologized to Mr Y.

He will receive £1,000 for the distress caused over his mother’s care and an additional £500 for the time taken to investigate his complaint, which the Ombudsman said was “unacceptable”.

Other recommendations adopted include:

• Referring the Ombudsman’s report to the Board and its equalities and human rights team to identify how consideration of human rights can be further embedded into clinical practice

• Reminding medical staff on the wards involved in Mrs X’s care of their professional obligations for ethical and clinical management for end-of-life care

• Considering the need for clinicians involved with Mrs X to undertake further training, and

• Reminding medical staff of the need to ensure adequate cover arrangements are in place when taking leave.