About the complaint

We launched an investigation after Mrs A complained about the care her sister, Ms B, received from Betsi Cadwaladr UHB when in Ysbyty Glan Clwyd (“the Hospital”) between May 2019 and May 2020. Ms B sadly died in May 2020.

Ms B who was aged 60 at the time of her death was a wheelchair user with long-standing health conditions who needed regular care to be delivered by nursing team.

Mrs A was concerned about delays in kidney treatment received by her sister. She also complained that her sister received inadequate bowel care when she was admitted to the Hospital in April and May 2020 with breathing problems. Ms B did not receive that care as no skilled staff was available to deliver it, and nursing staff did not update doctors that it had not been done.  Ms B developed new symptoms suggesting a bowel blockage, but was discharged without these symptoms being considered. Mrs A complained to the Health Board about these failings but was unhappy with its response.

What we found

We found that Ms B’s kidney treatment was reasonable. However, we were very concerned that Ms B did not receive the right bowel care and that she was discharged home without being seen by a doctor after she developed new symptoms. We also found that the Health Board’s own investigation into Mrs A’s complaint was not thorough or open enough. In addition, we found that the record keeping by the Health Board fell short of the requirements expected for both doctors and nurses.

Commenting on the report, Public Services Ombudsman for Wales, Michelle Morris, said:

I would firstly like to offer Mrs A and her family my sincere condolences. I recognise that they will find much of the detail in this report distressing.

It is clear from my report that there were shortcomings in medical and basic nursing care received by Ms B. I am concerned that although Ms B herself and Mrs A clearly informed the nursing staff of Ms B’s bowel care needs, that was not given the attention that it should have had – particularly given the possible serious medical consequences of not doing so.

We cannot say for sure that the fact that Ms B did not receive the bowel care she needed contributed to her death, as she was very unwell with other problems.  However, I have no doubt that the failings I have identified caused her avoidable and unnecessary pain and discomfort as well as compromised her dignity. 

Ms B was in hospital during the early days of the COVID-19 pandemic.  We understand and acknowledge that these were difficult and uncertain times with stretched NHS resources. However, Ms B’s care was simply not of an acceptable standard.

The NHS in Wales is now bound by statutory Duty of Candour, requiring them to be open and honest with patients and service users when things go wrong. In my view, the initial review of Ms B’s care undertaken by the Health Board lacked depth, rigour, openness and transparency required by that Duty.  

I am also very concerned that my office has identified similar problems of failings in basic nursing care, in record keeping, and in communication in previous cases we have investigated about this Hospital. 

What we recommended

We recommended that Betsi Cadwaladr University Health Board should provide an apology to Mrs A and pay her £4,500 for distress and having to pursue her complaint

In addition, we recommended that the Health Board should:

  • share her report with staff involved in Ms B’s care for them to reflect on their actions.
  • remind nursing staff at the Hospital about proper record-keeping.
  • complete a Bowel Care Protocol, and take steps to ensure that nursing and medical staff at the Hospital are trained to carry out manual bowel evacuation procedure.
  •  review its complaint handling and responses in light of the NHS Wales Duty of Candour which will be introduced in April 2023.

The Health Board accepted our recommendations.

Read this report here.