Sepsis: Cwm Taf Morgannwg failures 'led to woman's death'

Failures by hospital staff to diagnose a woman's ruptured appendix led to her death, a watchdog report has concluded.

The 49-year-old died from sepsis but that could have been avoided, the public services ombudsman said.

Her family said they had been "robbed" of a "loved woman" by doctors "found incompetent of doing the basic things."

Cwm Taf Morgannwg health board said it would "not forget this patient" and would also "take forward every piece of learning from this very sad case".

The investigation by ombudsman Michelle Morris was into the treatment of a patient, identified only as Mrs F in the report, who died in August 2020 at the Princess of Wales Hospital, Bridgend.

Ms Morris said: "This was a tragic case and our sympathy is extended to the family. We do not make the finding of avoidable death lightly.

"The injustice to Ms F and her family could not have been more serious."

Ms F went to A&E at the hospital on 17 July 2020, and again three days later, but staff failed to identify and treat her appendicitis.

She died of sepsis induced by a ruptured appendix the following month.

"Our investigation found no evidence that appendicitis was even considered as a potential diagnosis," Ms Morris said.

"Our clinical adviser in this case told us categorically that approach was inadequate."

If Ms F's appendicitis had been identified and treated, her death could have been avoided, the report concluded.

"Our clinical adviser... told us that death from appendicitis was uncommon. But death from undiagnosed appendicitis following discharge was even less common," Ms Morris said.

The ombudsman said she was concerned that the health board's investigation did not identify "learning points or recommendations" despite management not being sufficient on either 17 or 20 July.

The woman's cousin, who raised a complaint with the ombudsman, described her relative as "an incredible, bright, funny, unique [and] loved woman".

"The past 23 months have left us traumatised, broken, empty, angry, and extremely sad," she said.

She called for the hospital to make changes, saying "mistakes should not be happening in this day and age".

The ombudsman said the health board had "agreed to implement the recommendations in full" and managers have been asked to produce an action plan, showing how they will make improvements.

Paul Mears, chief executive of Cwm Taf Morgannwg health board expressed its "sincere apologies" to the family and offered its "heartfelt condolences as they continue to grieve her passing".

He added the health board accepted the ombudsman's findings and was "working at pace" to bring in the recommendations.

"I would like to provide reassurance to the patient's family, and to our communities, that we have put in place immediate improvements to prevent such a tragic event happening again," he said.

"At Cwm Taf Morgannwg we are committed to putting things right and to providing the very best healthcare services our communities deserve. We will not forget this patient and take forward every piece of learning from this very sad case."