Improving Patient Safety: Actions Taken by the Health Board Following a Complaint
Actions have recently been taken at a health board to improve patient safety, particularly those with learning difficulties. These changes were identified and reported through our advocacy service, who helped the patient make raise the issue with the Ombudsman. These changes include new staff training and new procedures to benefit all patients before discharge.
Following a complaint through our advocacy team, regarding the care of a patient with learning disabilities, a health board has implemented a series of actions aimed at improving patient services, particularly in managing safe discharge procedures. The complaint centred around a patient who had not undergone a Speech and Language Therapy (SALT) assessment to ensure she could swallow the medication prescribed for her upon leaving.
Following our support in making a complaint, the Ombudsman outlined several actions to ensure this doesn’t happen again. The health board has since put these measures into effect, ensuring their needs are fully met before they leave the hospital.
Key changes introduced include:
Documenting Baseline Mobility: When admitted, patients' mobility levels are now recorded, with the discharging nurse responsible for confirming that the patient has returned to their baseline mobility before discharge, alongside relevant therapy assessments.
Speech and Language Therapy Referrals: Where necessary, speech and language therapy referrals are made after swallow assessments to make sure patients can safely take oral medications.
Board Rounds: Regular "board rounds" have been introduced, where each patient’s situation is looked at in detail to understand their full healthcare needs.
Expanded Learning Disability Liaison Team: To better support patients with learning disabilities, the health board has expanded its liaison team dedicated to this group.
Staff Training: Welsh Government have directed a new e-learning module to train staff on supporting patients with additional needs.