Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs C complained about the care and treatment her late mother, Mrs A, received from Betsi Cadwaladr University Health Board (“the Health Board”) during 4 admissions to hospital between May 2021 and March 2022. In particular, Mrs C complained that the Health Board failed to correctly examine, identify and treat Mrs A’s symptoms between 29 May 2021 and 27 January 2022, provided poor nursing care to Mrs A following her admissions in August and October 2021 and January 2022 and communicated poorly with her about Mrs A’s condition during the admissions in August and October 2021.

The Ombudsman’s investigation found that there was a lack of completed documentation in relation to Mrs A’s nutritional and hygiene needs and that this did not adhere to national guidelines. In addition, there was incomplete documentation in relation to how nursing staff communicated with Mrs C and Mrs A, so it could not be determined whether communication was appropriate at all times. Both of these elements of Mrs C’s complaint were upheld.

The Ombudsman recommended that the Health Board apologise to Mrs C for the failings identified and to share the report with the nursing staff involved in Mrs A’s care to highlight the shortcomings in care identified, and to reiterate the importance of good communication and completing documentation in line with relevant guidelines.