Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms C complained about her late partner’s management and care at Ysbyty Gwynedd (“the First Hospital”) following a progression of his renal cancer in 2021. She also complained that the decision made not to transfer Mr B to a hospital based in England (“the Second Hospital”) on 3 September was not adequately communicated to him and/or his family.

The investigation found that Mr B’s chemotherapy treatment was appropriately stopped (given the risk of bleeding) for him to have surgical treatment at the Second Hospital and other follow-up investigations. The investigation concluded from the records that Mr B’s main pain seemed to be from the effects of prolonged coughing, caused by the cancer in his airway, and appropriate steps had been taken to try to address this through various interventions. The risk of bleeding from the tumour in Mr B’s airways – rather than Mr B’s coughing – was unavoidable, given the progression of his cancer.

It was identified that palliative intervention could have been raised with Mr B and his family, once Mr B’s disease progression in 2020 became clear, and not discounted because he was not end of life, given the holistic support palliative care can provide. In addition, more could have been done to monitor Mr B’s pain levels during his final inpatient admission and the investigation found documentary shortcomings around this. The injustice to Mr B and Ms C was that palliative care intervention might have meant that they were better prepared for what was to happen. In addition, palliative care could have helped if there were issues with Mr B’s pain management. To that extent Ms C’s complaint was upheld.

The investigation also concluded that there were communication failings around Mr B’s transfer to the Second Hospital and that the injustice for Ms C was that she had to complain further to get answers. This part of Ms C’s complaint was also upheld.

The Ombudsman’s recommendations included the following: that the Health Board apologise to Ms C and her family for the failings identified. In addition, as part of learning lessons, clinicians should be reminded of the palliative care team’s role as well as the need to monitor cancer patient’s pain levels during inpatient admissions. Changes around the cancer MDT documentation were also recommended.