Patients suffered from inadequate care, including amputations that were not needed, as a result of failings in vascular services in a hospital.
A damning report completed by the Royal College of Surgeons (RCS) of England found severe deficiencies in a number of patients' care at the establishment.
It reviewed the case record of 44 patients under the care of vascular services at Ysbyty Glan Clwyd, Denbighshire, Wales, as reported by North Wales Live.
Problems with documentation, keeping records, consent-taking and communication between medics were all highlighted.
Following the publication of the report, the Welsh Conservatives demanded a public inquiry be opened while the Plaid Cymru party called for the vascular services at Betsi Cadwaladr University Health Board t be returned to special measures.
As well as highlighting a “loss of dignity” suffered by some patients, the report’s findings included:
An amputee “needing to be carried to the toilet” by his wife after being discharged without a care plan;
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”;
Clinicians “possibly working outside the limits of their competence”;
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 stated: “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 mades 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 in April 2019.
However, after fears were raised by patients and staff about the new service at Ysbyty Glan Clwyd, BCUHB commissioned the RCS to conduct a review.
The first part of the report, published last summer, made nine urgent recommendations and raised other 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 Thursday, 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 BCUHB, 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 in 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 posts in the coming weeks to bolster the existing team across our North Wales network,” he added.
The report prompted an outcry from opposition politicians in the Senedd this afternoon.
Rhun ap Iorwerth, Plaid Cymru’s deputy leader in the Senedd, and spokesperson for health and social care, said he "couldn’t believe what he was reading” and called for special measures to “sort out this mess”.
Mr ap Iorwerth said that the lessons of the centralisation of services at Betsi is a “lesson for all of Wales” and warned against the principle of centralisation becoming “more important than the quality of care.”
First Minister Mark Drakeford conceded that centralisation can’t be a one-size-fits-all and must reflect community needs.
Mr ap Iorwerth said the report’s findings were “scandalous, heart-breaking and utterly damning”.
“There are real questions over whether Betsi Cadwaladr was ready to come out of special measures – conveniently, before the last election,” he said.
“We need assurance from the First Minister that vascular services in the north will go back into special measures, with targeted intervention to sort out this mess.”
Also raising the matter in Plenary today was Sam Rowlands, the Welsh Tories’ shadow minister for local government.
He called on Mr Drakeford to hold a public inquiry to “restore much-needed public faith” in Betsi’s vascular services.
The First Minister said he did not believe a lengthy public inquiry would be of much benefit to patients in North Wales.
Mr Rowlands said: “This report once again highlights the many problems still surrounding some services in my region and my constituents deserve so much better.
“I recently met with members of the Betsi Cadwaladr University Health Board to discuss this and other issues and was pleased to hear they are taking the matter very seriously.”
Mrs Morgan urged everyone “not to get drawn” into suggestions that the old vascular service model should be reintroduced, 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.”
Aberconwy MS Janet Finch-Saunders said she was “deeply alarmed” that the RCS review team found surgical notes and supporting correspondence to have been “disorganised, illegible or incomplete”.
She said it was essential that detailed recording of patient discussions and outcomes was put in place as quickly as possible.
Ms Finch-Saunders said: “With patients enduring unacceptable delayed waiting periods for MDT [multidisciplinary team] decisions and others discharged without a care plan, this report once again exposes much broader problems around the culture and management of the health board.
“It is clear that over-centralisation of services into Glan Clwyd has resulted in unacceptable lapses in expected standards, placing patients at risk.
“The people of North Wales deserve better, which is why I will continue to press to ensure our smaller hospitals play a greater role in our health service.”
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