Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

The Ombudsman investigated Mrs E’s complaints about the care she received from the Health Board during labour, and its response to her complaint. The investigation found that while reasonable efforts were made to enable Mrs E to have her baby at home, failings in the birth planning process meant that her transfer to hospital occurred sooner than might otherwise have been necessary. This complaint was upheld to this limited extent. The investigation found that there had been failures on several occasions to take reasonable steps to provide care in keeping with Mrs E’s birth plan. This complaint was upheld. The investigation found that there were a series of failings to provide Mrs E with adequate information to enable her to give informed consent for decisions relating to her care. The investigation found that an episiotomy was carried out on Mrs E without her prior consent. These complaints were upheld. The investigation found that there was no failure to provide care which would have avoided the need for medical interventions during Mrs E’s labour. This complaint was not upheld. Finally, the investigation found that the Health Board’s complaint response, while reasonably timely, was not adequate. This complaint was partly upheld. The Health Board agreed to the Ombudsman’s recommendations, including to apologise and make a financial redress payment of £1500 to Mrs E, and to arrange training for midwives and obstetricians to reinforce learning points regarding supporting informed consent and effective birth planning.