HEALTH inspectors have raised concerns about how Gwent's health board handled a complaint about the care of a 32-year-old woman who died of a rare stomach cancer.
The patient, referred to as Miss A in a 50-page Healthcare Inspectorate Wales (HIW) report, died in May 2010, 13 months after initially seeking help from her GP following a prolonged bout of indigestion.
Despite persistent and worsening symptoms and a series of visits to her GP and to A&E at Nevill Hall Hospital, including an endoscopy in June 2009, she was not formally diagnosed with linitis plastica until February 2010.
Shortly before she died, the mother-of-one's family complained about the standard of care she had received, and subsequently about the health board's action plan drawn up in response to the findings of an independent review.
HIW was then asked to review that action plan by health board chief executive Dr Andrew Goodall.
The HIW report details how Miss A's initial symptoms, including a feeling of food sticking in her upper chest, feeling full all the time, and weight loss, worsened in the months after her initial visit to her GP.
Towards the end of 2009, she began a series of visits to A&E at Nevill Hall culminating in one early in January 2010 when she was discharged despite tests showing that she was suffering acute renal failure.
She was readmitted the following day and taken to intensive care the day after that , followed by transfer to the University Hospital of Wales in Cardiff, where a month later, her cancer was diagnosed.
The initial independent report highlighted shortcomings in the care provided by her GP surgery, in the way the endoscopy process and follow-up was handled, and in the way A&E at Nevill Hall dealt with Miss A.
HIW concluded that while a good number of the action plan proposals had been put in place, there was concern over the complaints process in regard to Miss A's case, which it concludes was "disjointed" with some staff being unaware of the complaint until well into the process or not until the action plan was drawn up.
There was criticism that a consultant physician attended a meeting with Miss A's family to discuss the care she received, for only 10 minutes, which was "unintentionally interpreted as down-playing the importance of the concern from the perspective of the family."
While commending the health board over measures it has taken following Miss A's case, the report raises particular concern about there having been no report produced explaining the reasoning behind her discharge from A&E despite having kidney failure.
This was identified in the independent review as having been down to human error and the health board's action plan called for a report. But the consultant physician responsible felt this was unnecessary as human error had been established.
HIW however, is urging that such a report be produced "as a valuable learning mechanism and (to) help minimise such circumstances arising again."