Wrexham Maelor: Woman’s death from sepsis “could have been prevented”

The death of a woman from sepsis as a result of a misdiagnosis was a “grave injustice” and could possibly have been prevented, a report says.

The Public Service Ombudsman for Wales concluded that the woman, identified only as Mrs K, could have survived if she had received appropriate treatment for her acute pancreatitis “from the outset”.

Mrs K, a patient at Wrexham Maelor Hospital, died on 31 January 2022 from biliary sepsis, a severe infection of the bile ducts.

The Betsi Cadwaladr Health Department apologized “unreservedly” and directly to the woman’s daughter for the identified failures in the care of her mother.

The ombudsman concluded that the health authority had “missed opportunities” to properly diagnose and treat Ms. K., for example by failing to identify her gallstones.

In addition, they found “little or no evidence” that she and her family had been adequately informed of the severity of her condition.

Welsh Public Service Ombudsman Michelle Morris said the failure to identify Ms K's gallstones in January 2021 was “an unacceptable failure of service which caused sustained and serious injustice to Ms K and her family”.

She said: “If Mrs K had been treated appropriately from the beginning, her acute pancreatitis would have been successfully treated and her deterioration and death might ultimately have been prevented.”

Ms Morris said she was also “deeply concerned” about the health department's apparent “lack of candor” in its response to the complaint.

She added that doctors had shown a “lack of objective consideration” during their investigation and “continued to fail to identify and acknowledge deficiencies in Ms K's treatment.”

She further said she was aware that the treatment took place during a period of Covid restrictions, but added that even with those restrictions, the patient would have had access to appropriate treatment within a few weeks.

The Ombudsman has recommended that Betsi Cadwaladr Health Board issue a full apology from its chief executive to Ms K's daughter and pay her £4,000.

It also stated that the case had to be investigated by the health department to determine why Ms. K. was misdiagnosed.

In a statement, Betsi Cadwaladr chief executive Carol Shillabeer said: “On behalf of the health department, I unreservedly apologise for the identified failings in the care of Ms K.

“We have not reached the expected standard.”

It went on to say that the patient's daughter had been sent “a direct letter of apology” to “assure her that we are addressing the concerns raised.”