‘My mother was told she had five to 10 years to live - five days later she was dead’

-Credit: (Image: WalesOnline/Rob Browne)
-Credit: (Image: WalesOnline/Rob Browne)


A woman who says her mother was told she had five to 10 years to live after a shock diagnosis has told of how she died days later. Kay Picton, 70, was described by her daughter Dawn Edwards as a “fit and healthy woman who hadn’t had an operation for 50 years”. She had renewed her passport to go travelling just a week before. But she died in the care of Cwm Taf Morgannwg University Health Board on June 24, 2022, days after she’d had a routine procedure to treat cancer of the bile duct.

Ms Edwards claimed that despite her mother being told the procedure was relatively routine a “lack of care” including insufficient monitoring, pain relief and oral care led to her mother’s spiral and death afterwards. In an interview with WalesOnline she has claimed her mother “ultimately died with very little dignity” at Royal Glamorgan Hospital in Pontyclun, Rhondda Cynon Taf.

Ms Edwards said her complaints to the hospital over her mother’s care fell on deaf ears in the following months so she decided to take it to the Public Service Ombudsman for Wales. But she said the ombudsman couldn’t carry out a comprehensive investigation of what happened to her mother because the hospital had lost crucial documents relating to her care.

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The ombudsman has warned the health board about future record keeping in its report on the case published last week. It was scathing about the health board's failure to properly engage with its investigation. The Ombudsman for Wales, Michelle Morris, described it as "unacceptable and of serious concern to the public". And she also found Ms Picton did not receive appropriate observations at the hospital and that the documentation of assessment of pain was below standard.

“My mother initially attended the accident and emergency department at the hospital with backache, vomiting and weakness,” Ms Edwards explained. “She arrived at A&E on the Sunday and was moved to ward five at the hospital. She had a CT scan on June 16 and after that she was diagnosed with cholangiocarcinoma which is cancer of the bile duct. It was agreed with mum that she would have an ERCP procedure on June 24 at the hospital. Further scans later showed the cancer had likely spread.”

Kay Picton, pictured with granddaughter Katie, had been looking forward to Katie's wedding, but she died aged 70 from complications from a routine procedure -Credit:WalesOnline/Rob Browne
Kay Picton, pictured with granddaughter Katie, had been looking forward to Katie's wedding, but she died aged 70 from complications from a routine procedure -Credit:WalesOnline/Rob Browne

An ERCP procedure, which is an endoscopic retrograde cholangiopancreatography, involves a patient having a long thin tube inserted into their intestine via their oesophagus and stomach before a dye is injected through the tube to highlight the organs during an X-ray. If needed specialised equipment can be used to break up stones or leave a stent in the bile duct to drain bile, which was performed in Ms Picton’s case.

“Hours after the procedure at around 2.30pm I went to the hospital to visit mum with no expectation that anything would be wrong,” Ms Edwards said. “When I got to the ward I opened the door which was fully closed and when I got in there mum was writhing around in pain, crying and vomiting, and asking God to let her die. I was in disbelief. There wasn’t a nurse in sight and it was clear to me she hadn’t been attended to for some time. When I asked where a nurse was for mum I was told they were on break. I’m a nurse myself and understand the importance of having a break, but surely not when your patient is in that state.

“When you come back to a ward after a procedure you’re supposed to have a set number of observations. To start with it should be every 15 minutes. She didn’t have that. We knew that because of the state we found her in.

“That weekend we were told they didn’t have enough staff to see to her needs so we stayed down there all weekend. We know they’re short on staff there but it wasn’t good enough. My mother couldn’t live unless she had oxygen assistance but they said they couldn’t have someone there observing her constantly because they didn’t have the volume of staff to commit someone to that.

“By that time my mother had gone delirious so was trying to take her oxygen mask off. She needed constant monitoring. Her oxygen levels were around 70% and her brain was essentially being starved of oxygen.”

Dawn Edwards said her mother Kay Picton, pictured, would never have signed a consent form for the procedure had she been of sound mind to read the document properly -Credit:WalesOnline/Rob Browne
Dawn Edwards said her mother Kay Picton, pictured, would never have signed a consent form for the procedure had she been of sound mind to read the document properly -Credit:WalesOnline/Rob Browne

The ombudsman’s report indicates Ms Picton was likely reviewed at around 1pm, an hour and a half before Ms Edwards said she discovered her mother in such a state. Ms Edwards said it transpired her mother had experienced severe complications as a result of the ERCP. The hospital said they believed this was due to pancreatitis which is one of the more common side effects of an ERCP and wouldn’t usually result in a patient’s death. Ms Edwards said she was convinced her mother had developed sepsis which was never diagnosed. In May a coroner's inquest concluded 57-year-old Janet Williams died in the same hospital following the same procedure after developing sepsis.

“We feel we were not given the full information about the ERCP procedure and neither was mum,” Ms Edwards continued. “The hospital says mum signed the consent form after reading a leaflet discussing the potential risks of the procedure. We’ve asked for that consent form that mum signed but it’s not there. They say they’ve lost it.

“I don’t believe my mother would have consented had she been fully aware of the risks. We believe mum’s sanity was quickly deteriorating while she was in hospital and she was not fit to make a decision to sign that consent form. My mother wouldn’t have read that leaflet properly. She was in no fit state to read that. She had just been told she had a life-limiting condition which would likely kill her, so she wasn’t in a fit state to make a decision at the time.”

Dawn Edwards took her mother's case to the ombudsman who has told the health board it must apologise to the family -Credit:WalesOnline/Rob Browne
Dawn Edwards took her mother's case to the ombudsman who has told the health board it must apologise to the family -Credit:WalesOnline/Rob Browne

The ombudsman Michelle Morris noted in her report: “My investigation found the ERCP consent form was lost and it was not possible to determine if (Ms Picton) had been provided with sufficient information to make an informed decision. This caused ongoing uncertainty to her family and this complaint was upheld. My investigation also found that (Ms Picton) did not receive appropriate post-ERCP observations, that the documentation of assessment of pain was below standard, and there were missed opportunities to ensure she received appropriate oral care.”

Ms Edwards said the consent form for the procedure was “one of a few pieces of paperwork” which the hospital said had been lost. As Ms Picton spiralled, a consultant working for the hospital decided to place a do not attempt resuscitation (DNAR) notice on her.

“It was the same with the DNAR,” Ms Edwards explained. “That was put in place without our consent or knowledge until after that decision had been made. We understand they can do that, but at the very least we’d have liked to have been made aware. To me as a nurse it is a matter of respect to tell the family of the patient a DNAR was to be made. Most of all because I’m 100% sure my mother wouldn’t have wanted a DNAR placed on her. She’d have done everything she could to try to carry on living. She had plans to travel and had renewed her passport just the week before. She had so been looking forward to her granddaughter's wedding too.

“I am aware that the consultant who ultimately made the decision to place the DNAR on mum had done so while working from home. I am sure they had actually never met my mother. Ultimately I think mum would probably have died anyway, but I still feel the loss of documents was indicative of a general lack of care on the ward which I believe contributed to her death. Another document which was apparently lost was an ERCP pathway which included information regarding her care after the operation.”

The ombudsman found the decision to place a DNAR on Ms Picton was clinically reasonable and that the consultant working with clinicians from home did not make a material difference to the decision. The ombudsman told the health board it must apologise to Ms Edwards over the case and “remind relevant staff of the importance of record keeping and ensuring patient records are retained”. It added the health board must “remind relevant staff of the post-ERCP procedure pathway monitoring requirements".

The health board apologised to Ms Picton's family on behalf of the Royal Glamorgan Hospital -Credit:Chris Fairweather/Huw Evans Agency
The health board apologised to Ms Picton's family on behalf of the Royal Glamorgan Hospital -Credit:Chris Fairweather/Huw Evans Agency

Ms Edwards added: “At the very least I believe if mum had more appropriate care she would have had a more dignified death. We know the hospital says mum likely had pancreatitis. We strongly believe mum had sepsis which should have been looked into and potentially treated sooner.

“Ultimately what hurts the most is that my mother passed away in such an undignified manner, suffered a lot of pain and had no time to put her affairs and goodbyes in order. It's not the way we ever thought my mum's life would end. It's been a nightmare. I now suffer with PTSD and can't rest at night with all the: 'What if we had done this or that.' We get that the outcome wasn't going to be good, but it shouldn't have been that bad."

A spokesperson for Cwm Taf Morgannwg University Health Board said: “We extend our sincere apologies to the family for the instances where their family member’s care fell below the high standards we expect for all of our service users. Implementing the learning from this case we have ensured that all of our relevant clinical teams follow the correct post-procedure pathway, including retaining patient records where appropriate.

“We fully acknowledge the Public Service Ombudsman for Wales' report findings and recognise our shortcomings in failing to respond promptly. To address this, we have established a robust system, with executive oversight, to handle future ombudsman cases efficiently. Delivering safe and effective patient care remains our top priority and we can provide reassurance that we have strengthened our processes as a result of the lessons learnt in this case. We appreciate the family's patience during this challenging time.”