Report highlights ‘alarming, systemic misdiagnosis’ of woman who died after bowel cancer surgery

Jez Hemming, local democracy reporter

An Ombudsman’s report has highlighted what he called the “alarming, systemic misdiagnosis” by a health board of woman who died after bowel cancer surgery.

Grandmother Ann Jones, who was 69 and came from Rhyl, died on August 24, 2019, of a blocked blood vessel in her bowel, inflammation of the abdominal wall and a blood clot in her lung.

The report found “despite conspicuous radiological and clinical evidence” doctors at Betsi Cadwaladr University Health Board incorrectly attributed the failure to eat and keep food down after her operation to a “food phobia”.

The real reason the mum of three had been in pain and unable to eat was because she had a small bowel obstruction (SBO) which was not spotted by doctors.

The Public Services Ombudsman for Wales said doctors at Ysbyty Glan Clwyd and Llandudno Hospital failed to “adequately investigate and appropriately treat” Mrs Jones’ abdominal pain and weight loss symptoms.

He also said they “failed to assess (Mrs Jones’) frail condition accurately” and discharged her without “appropriate home care support in place”.

He found a secondary cause of her death – an ischaemic bowel – was not identified from their scans or investigations.

Denbighshire council was criticised for not having appropriate care in place and responding to complaints from the family six months after the health board.

Upholding four of the five complaints pursued by Mrs Jones’ family, the Ombudsman’s report said:  “The Ombudsman could not definitively conclude the failure to identify and treat the SBO meant (Mrs Jones’) death was preventable.

“This was because it was unclear whether she could have sustained further surgery, given her frail condition and comorbidities.

“The Ombudsman nevertheless considered this to be an alarming, systemic misdiagnosis and considered the uncertainty surrounding whether an opportunity to surgically intervene was lost to be, in itself, an injustice to (Mrs Jones) and her family.”

Mrs Jones’ daughter Charlotte Finlay said: “The report was quite important for me because I have no stigma of my mum having anorexia.

“I fought that the whole year because I had all these psychiatric nurses treating my mum as if she was a child.

“Towards the end of July she was given anti-psychotic drugs but at that time I was just desperate for them to give her some comfort.

“Mentally what they put her through is something I’m not sure you ever get over really – it shouldn’t have been done to her.

“The reason why we did everything was just to get some answers and justice for our mum – I can’t speak highly enough of the Ombudsman really.

“I can sit and praise the fantastic work the health board has done but we wanted recognition of the failings.”

What happened

Mrs Jones completed a home screening test in 2018 and discovered she had cancer of the colon in December.

Near to the time it was due to be removed, in January 2019, she developed acute pain and it was discovered an abscess had formed around the tumour.

The report highlighted to the family the tumour was more extensive than they’d realised at the time but the operation successfully removed the growth.

Mrs Jones, who survived breast cancer around 20 years previously, approached the operation and the planned chemotherapy afterwards positively according to Charlotte.

She said: “She was a fighter – a very positive lady – and lived every day, it’s awful to say, but as if it was her last. She made the most of her life.

“She was a little bit down about it, which is normal because she’d already been through a lot, but she was fit and healthy.

“She was going to beat it and that was that really. She was a very determined, strong woman.”

However within five days of surgery Mrs Jones was in pain and continually vomiting as she struggled to keep her food down.

Charlotte, who lives in Northern Ireland, said: “She couldn’t tolerate any kind of food. It scared her how sick she was in hospital.

“Mum came to see me in the February. I’ll never forget picking her up from the airport. It was clear she was very unwell.

“She stayed with me for two weeks and although she managed to keep a little bit of food down, the pain was very clear.”

Charlotte claimed doctors told Mrs Jones and her family the pain she was experiencing was “part of the healing process”.

Suffering from chronic diarrhoea she was told she needed to eat more solid food to get her strength up for chemotherapy but her albumin levels (a blood protein which points to liver and kidney health and can suggest nutritional deficiencies) were continuing to drop.

‘Guilt’

Mrs Jones made the first of four 999 calls over the coming months on March 19.

Charlotte said: “We were told the doctors couldn’t see anything and they thought she had psychological issues – a phobia of food – which didn’t sit well with me.

“I was arguing that point and (the diagnosis) made her feel very depressed.”

Between January and June Mrs Jones’ weight plummeted and in June she was fitted with a nasal feeding tube but her daughter said she “couldn’t tolerate enough food and she was losing her hair”.

Charlotte said: “I questioned is she going to live? I hadn’t seen her for a while and I walked in and she was just wailing.

“Mum felt a lot of guilt. She would have done anything to stay alive at this point.

“She said ‘how long can I suffer like this’? It was very painful to watch.”

Doctors agreed to investigative surgery and Mrs Jones was admitted to Llandudno Hospital in July to help get her strength up.

However, Charlotte said she was placed on a ward with Alzheimer’s patients, without the psychiatric support she’d been given in Ysbyty Glan Clwyd, Bodelwyddan.

Her daughter said she deteriorated further, adding: “She said ‘why am I here’?

“For a short time a woman recovering from a stroke was in there with mum and for that short period of time she was like a different person because she could talk to somebody – it was very, very disturbing.”

Mrs Jones was discharged from hospital at her lowest weight, according to her daughter, and didn’t want to be at home on her own.

Charlotte claimed her mum couldn’t get upstairs to her bathroom and received care from Denbighshire council for a day but it was “pulled”.

She said: “They came for a day and because mum would not get washed, she wasn’t able to walk more than a couple of steps and she wouldn’t have food made for her because she wasn’t eating.

“They were saying ‘what can we do’? We said ‘even if you changed the commode for her’.

“I visited her in late July and she was being discharged, that’s why I flew over.

“Mentally that time after she was discharged it’s something…unfortunately it’s the last time I saw her alive. That’s why it’s quite raw.”

Charlotte spoke to her mum before her last admission to hospital in August, 2019.

She said: “Everything she spoke about to her was pain-related which is something we can’t get past at the moment really.”

What the Ombudsman said

Commenting on the report, Public Services Ombudsman for Wales, Nick Bennett, said: “This tragic case involved an alarming, systemic misdiagnosis.

“Numerous significant failings and deficiencies took place before, during and after (Mrs Jones’) discharge from hospital.

“These failings impacted upon (Mrs Jones’) human rights in terms of her dignity but also her quality of life.

“There was also an impact on the patient’s family’s rights in terms of witnessing her debilitating decline.”

He also criticised the coordinating of responses to a complaint from Mrs Jones’ son Darren “which resulted in the Council’s response being received six months after that of the Health Board”.

He ordered both the health board and Denbighshire council to send him a written apology and £250 each as redress and told Betsi Cadwaladr UHB to pay £5,000 “in recognition of the distress the findings of his report will cause to (Mrs Jones’) family”.

The responses

A spokesman for Denbighshire council said: “We are sincerely sorry for the distress caused to the family of (Mrs Jones) and have provided (her son) with a full written apology following the findings of this report.

“The council fully accepts the findings and recommendations made in this report and we are making sure these are implemented with the relevant staff and departments involved.”

Gill Harris, deputy chief executive of Betsi Cadwaladr UHB, said: “We sincerely apologise to (Mrs Jones’ son) for the failures in his mother’s care and for the way his subsequent complaint was handled.

“We accept the Ombudsman’s findings and recommendations in full and we are currently working with the relevant clinical teams to implement the necessary improvements.”