Patients suffered unnecessary harm, a loss of dignity, and substandard care as a result of failings in vascular services in one part of Wales.
A report by the Royal College of Surgeons (RCS) of England reviewed the case records of 44 patients who were under the care of vascular services at Betsi Cadwaladr University Health Board.
It found serious deficiencies in some patients' care as well as issues with record keeping, consent-taking, communication between clinicians, and documentation.
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Among the report's damning findings included:
- An amputee needing to be 'carried to the toilet' by his wife after being discharged without a care plan;
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A patient being given an 'unnecessary and futile' amputation when 'palliation and conservative therapy should have been considered instead'. The report states that the risk from major amputation for the patient was 'extremely high';
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Clinicians 'possibly working outside the limits of their competence';
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In seven cases clinical records did not include patient outcomes while in six cases there were no clinical records available for the review team to assess.
The report states: "The review team were strongly of the opinion that the majority of the surgical notes and supporting correspondence, results and reports were disorganised, illegible and incomplete."
While the review team noted good practice in some areas the report makes nine recommendations including five urgent ones "to address patient safety risks".
Health minister Eluned Morgan said she was "disappointed and concerned" by the RCS report and expects the health board to address the issues "with immediate effect".
She said: "The cases reviewed here involve real people and their families and there will be many others who may be worrying about the quality of the care they have received or are about to receive and whether this service is safe.
"I expect the health board to address these issues with immediate effect and put a plan and processes in place to contact and review patients appropriately and sensitively, to provide them with information and assurance as well as to address the other recommendations made by the RCS."
Vascular services were centralised from Ysbyty Gwynedd in Bangor and Wrexham Maelor Hospital to Ysbyty Glan Clwyd, Denbighshire, in April 2019.
However, after fears were raised by patients and staff about the new service at Ysbyty Glan Clwyd, Betsi Cadwaladr UHB commissioned the Royal College of Surgeons to conduct a review.
The first part of the report, published last summer, made nine urgent recommendations and raised issues including too many patient transfers to the centralised hub, a lack of vascular beds, and frequent delays in transfers.
The second part, published on February 3, focused on the clinical records of 44 patients dating from 2014 – five years before centralisation – to July 2021, two years after the hub at Ysbyty Glan Clwyd opened.
Commenting on the report Dr Nick Lyons, executive medical director at Betsi Cadwaladr UHB, said: "I am very concerned to note the review's findings in relation to the quality and consistency of care provided – we must do better.
"I am clear the board decision to consolidate the service in a hub and spoke model was the right one and is still advocated by the Royal College of Surgeons as the best for north Wales.
"It should be noted that this report covers a period from 2014 through to July last year so this is not necessarily a snapshot of where we are now and some improvements have already taken place."
To ensure improvements are embedded into ways of working Dr Lyons said an audit is being carried out of the quality of patient notes and documentation of patient consent across the health board. The health board has also convened a panel to oversee a review of clinical notes.
"We have invested in a state-of-the-art hybrid theatre and a committed multidisciplinary vascular team, which we continue to recruit to. New colleagues are taking up post in the coming weeks to bolster the existing team across our north Wales network," he added.
Welsh Conservative and shadow health minister Russell George MS said: "This report is another in a long line highlighting the deficiencies in healthcare in north Wales. Vascular services are extremely important and substandard provision is no trivial matter so Betsi Cadwaladr should not waste time in implementing the report’s recommendations.
"I do welcome the strong assurances the health board has provided the [health] minister on the recommendations, the steps to strengthen clinical leadership, and the intention to enter into an arrangement with a larger vascular service in England for greater oversight and support.
"However the minister could herself show more leadership: far too often during the pandemic we have seen her abdicate responsibility for resolving issues to health boards and it seems that is set to continue for the NHS in general.
"Labour must get a grip on the NHS instead of leaving the health board – and so the people of Wales – to fend for itself."
Mrs Morgan urged everyone "not to get drawn" into suggestions that the old vascular service model should be re-introduced because it would not be supported by the Royal College of Surgeons.
"The implementation of the new model has faced significant difficulties and in many respects has been poorly executed," she said.
"I do not underestimate how challenging it must be to alter long-standing care pathways and to get everyone on board with a system-wide change in particular in the middle of a pandemic but there are many things which have not been done well and there should be no excuses for this.
"For the sake of people in north Wales who need this service, and the staff working to provide this care, we must now do all we can to ensure the health board implements it properly to make the pathway seamless and to improve outcomes. This is meant to be a flagship service and I am determined that it will become so."
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