BCUHB criticised after patient fails to give 'informed consent'

The Ombudsman launched an investigation after receiving a complaint from a patient, referred to as Ms A, who had a history of Crohn’s disease and wanted to have children, about the care she received from Betsi Cadwaladr University Health Board (BCUHB) and Liverpool University Hospitals NHS Foundation Trust which had been commissioned by the health board. 

Her concern included management and care following surgery for her inflammatory bowel disease in 2019, whether she was properly consented for surgery address her fluid collections and pelvic infection in March 2022, as well the post-operative care and treatment and the handling of her complaint. 

Multiple failings across various aspects of Ms A’s treatment and care were uncovered as part of the investigation, including failings in colorectal care, and in relation to gynaecological referrals, investigations and treatment undertaken by another English Trust. This led to Ms A having persistent infection and ill health for nearly three years before she received surgical treatment in March 2022.

It is understood that Mrs A's treatment over the years took in Ysbyty Glan Clwyd in Bodelwyddan as well as the Royal Liverpool University Hospital.

The Ombudsman found that Ms A did not give informed consent for this surgery - she only signed the consent form on the day of her surgery and there was no record of prior discussion with her of the possibility of her having a hysterectomy during the surgery. 

This failure led to the ombudsman highlighting that Ms A’s Article 8 rights (the right to respect for private and family life) were potentially engaged. 

Commenting on the report, Public Services Ombudsman for Wales, Michelle Morris, said: “I am mindful of the profound injustice caused to Ms A as a result of the significant failings that have occurred in her case.  

"I am extremely concerned about the process by which Ms A gave her 'consent' for the surgery in March 2022.  The relevant guidance makes it clear that consent is not simply a matter of completing and signing a form.  Instead, consent is a process which should begin well in advance of the day of the surgery and any discussions should be clearly and separately recorded as part of the consenting process. This did not happen here.

"This sad case also highlighted the wholly inadequate contract monitoring arrangements in place at the Health Board. Public bodies must have robust governance arrangements and must ensure that patient safety and the monitoring of the quality of services is in place. 

"The Health Board’s failure to monitor patient safety and service quality led to it missing crucial opportunities to address poor performance. With more effective contract monitoring, many of these failings could have been prevented."

Mrs A's evidence detailed that Mrs A had signed a consent form for surgery as she was getting ready to go into theatre and that she had been "anxious and distressed" at the time. 

She said she was "unaware" that a hysterectomy was a possible outcome and only found out this had happened when a nurse told her after she woke up from the surgery.

The ombudsman report said: "She [Mrs A] said that none of the operating team came to talk to her about it or to review her recovery and she was forced to ask clinicians who had not been involved to explain what had been done. Ms A said she had not known whether the gynaecologist had been present during the operation until it was confirmed by my office."

Ms A, who has sought counselling and mental health support to help come to terms with her ordeal, described her whole experience as being “horrific”.

She said that mentally she has had "so many dark days”.

She said: "I’m avoiding people; people ask me about my health and I’ve lost my confidence as I’m not steady enough to talk about this, I know I’ll burst into tears and I don’t want to do that. I know I’m a different person, my family keep telling me that. I feel like a shadow of my former self."

The report added that "Ms A has been left devastated as she wanted to have children, and she grieves the loss of that opportunity".

The Ombudsman made the following recommendations, which the Health Board has accepted:

• Apologise to Ms A and share the report with relevant Health Board members.
• Request the English Trust to review Ms A’s case, remind clinicians of informed consent and their professional obligations, and share key learnings through a case study of this case.
• Request the Trust’s Surgeon to reflect on the case and discuss improvements to her clinical practice at her next revalidation.
• Seek written assurances from the Trust’s Chief Executive that clinical failings are being addressed and provide compliance evidence to the Ombudsman.
• Health Board to prioritise, complete and implement a Commissioning Assurance Framework which gives proper consideration to patient safety.

Carol Shillabeer, BCUHB Chief Executive Officer, said: “I sincerely apologise for this patient’s poor experience and the Board is fully committed to taking forward learning from this case.

“It is essential for the health of our population, we work with other health boards and trusts. It is clear we need to improve our oversight arrangements for these commissioned services and we fully accept the Ombudsman’s findings.

“We have already started to make those improvements and our new commissioning approach will help that further.”