The Complaint

We launched an investigation after Mr B complained that the Health Board failed to provide appropriate and timely treatment to his wife (Mrs B) after she was admitted to hospital with suspected appendicitis.

Our Investigation

We found:

  • a failure to provide Mrs B with the expected level of care after the surgery to remove her appendix
  • a failure to identify the underlying cause of Mrs B’s breathing difficulties and to provide appropriate and timely treatment
  • a failure to recognise signs that Mrs B’s condition was deteriorating and to take appropriate action
  • that, on a balance of probabilities, Mrs B’s cardiac arrest and lengthy admission to the Intensive Care Unit would likely have been avoided if she had received appropriate care.

We were concerned that these events took a considerable toll on Mrs B’s physical and mental wellbeing. Mrs B had been left with health and mobility problems that she would not have expected to have to cope with in her 50s and which may significantly limit her quality of life for years to come.

We believed that Mr B had also suffered significant injustice through the distress he experienced during his wife’s admission and afterwards, in adapting to the need to provide ongoing physical and psychological support to her.

“Own Initiative” Investigation

During the investigation, a concern arose that the Health Board had failed to arrange appropriate follow-up and treatment for Mrs B in response to a scan in September 2017.  As a result, we used the recently introduced “own initiative” power to extend the investigation to look at the concern, of which Mr and Mrs B had been entirely unaware.

The “own initiative” investigation found that, in response to the scan result, the Health Board should have arranged to remove Mrs B’s appendix but failed to do so.

As a result, there was a missed opportunity to avoid the deterioration in Mrs B’s health which occurred after she developed appendicitis in 2019.

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

“This sad case demonstrates why the “own initiative” power is needed, in the public interest, and for individuals who come to our office.

Mr and Mrs B were entirely unaware of the missed finding on the CT colonography, and the problem was not identified during the Health Board’s own investigation of the complaint. Had my office not started an “own initiative” investigation to consider this, this significant failing leading to serious injustice to Mr and Mrs B would otherwise not have come to light.”


We recommended that Betsi Cadwaladr University Health Board should apologise to Mr and Mrs B and pay them £10,000 to reflect the serious injustices arising from the missed CT colonography finding in 2017 and the poor post-operative care in 2019.

We also recommended that the report should be shared with the First and Second Consultants for the purposes of reflection and discussion at their next annual appraisals, in addition to providing evidence to her office that the report has been discussed at a surgical clinical governance meeting and appropriate learning points shared with relevant clinical teams.

To read the full report, click here.