There were failings in the care of a vulnerable man who choked to death on a piece of toast, a report has found.
The Public Services Ombudsman for Wales investigated the care of a man, referred to as Mr N, who died in March 2017.
Mr N was being looked after by Gwynedd Council, Betsi Cadwaladr University Health Board, and Cartrefi Cymru, a registered care provider.
All parties have accepted the findings and apologised to his family.
Mr N had drug-induced psychosis and a severe brain injury and required round-the-clock care.
At the time of his death, he was living in his own rented home with a jointly funded package of 24-hour care, provided by Cartrefi Cymru.
Ombudsman Nick Bennett investigated claims made by Mr N’s mother, known as Mrs M, about the care given to her son.
He concluded that while he found “maladministration and service failure” on the part of the council, health board and Cartrefi Cymru, he could not say any of the failings caused or contributed to Mr N’s death.
“However, Mrs M will be left with the uncertainty of not knowing whether, but for these failings, things might have been different and the incident might not have happened,” he added.
Mr Bennett found Cartrefi Cymru failed to undertake a comprehensive assessment of the risk of Mr N choking, even though he was taken to hospital after choking in 2016, and problems with his chewing and swallowing were recorded as far back as 2015.
On 3 March 2017, Mr N choked on a piece of toast while eating alone in his bedroom and died, despite first aid being administered by his carer.
An inquest found the medical cause of death was choking and recorded the death as an accident.
Mr Bennett said he was “dismayed” by the inability of all three bodies to provide key documentation, amounting to maladministration.
The report said there was no documentation relating to the awarding of the care contract to Cartrefi Cymru or any specific terms relating to Mr N’s care needs and the responsibilities of parties involved in his care.
It was also found there was no documentation to demonstrate the council, as lead commissioner, had monitored the delivery of care to Mr N.
Mr Bennett said: “I am extremely concerned at the multiple failings in communication between the three bodies involved in providing care to Mr N.
“It’s impossible to say with any certainty whether any of the bodies involved had seen a risk assessment relating to the risk of him choking, but given his obvious vulnerabilities, it was clear to me that the care provider should have carried out its own risk assessment at the earliest opportunity.
“I sincerely hope lessons are learned from this tragic case.”
The council and health board agreed to several recommendations, including apologising to Mr N’s family for the failings identified. Cartrefi Cymru agreed to provide refresher training for staff.
Cartrefi Cymru said: “The report highlights that the documentation relating to Mr N’s care was in need of review and improvement and although, importantly, the ombudsman did not conclude that this was a factor in Mr N’s death, it is rightly described as a failing on the part of all the agencies involved.”
Gill Harris, the health board’s deputy chief executive and director of nursing, said: “We wholeheartedly apologise for the failings identified by the ombudsman and we have already begun the process of working with Gwynedd Council and Cartrefi Cymru to act on his recommendations.”
Gwynedd Council added: “Although the ombudsman did not find that this contributed to the tragedy, it remains a matter where there were failings.”