Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs B complained about the standard of nursing care provided to her late stepfather, Mr A, during his admission to Ysbyty Glan Clwyd (“the Hospital”) during February and March 2021. Mr A had terminal cancer and, as a result of surgery, he was no longer able to speak or breathe in the usual way. He used a writing board to assist with communication and maintained contact with family via his iPad and phone.
The Ombudsman found shortcomings in the care provided and upheld several aspects of the complaint. These were that:
• Mr A’s neck stoma was not covered when he attended an outpatient appointment.
• There was a failure to complete nutritional assessments and to weigh Mr A regularly. There was also no apparent multidisciplinary plan in relation to whether nasogastric feeding was indicated for Mr A.
• The care of Mr A’s PICC line (peripherally inserted central catheter) was substandard.
• There were shortcomings in holistic care planning for Mr A, in terms of assessing his mental health needs and ensuring that he had effective means to communicate and maintain contact with his family.
The Ombudsman also noted that a discussion could have taken place with Mrs B and Mr A to address some of the ongoing care concerns while Mr A was in hospital. This was a missed opportunity.

The Health Board agreed to the following recommendations:
Within 1 month:
a) A formal written apology to Mrs B for the identified shortcomings in care, and that the opportunity to resolve these at an earlier stage was missed.
Within 2 months:
b) To discuss, at an appropriate medical forum, the issues highlighted in the report about the communication between clinical teams involved in Mr A’s care (MDT). This specifically relates to whether an earlier multi-disciplinary plan about his management could have been made, including critical areas of care such as nutrition.
c) To review the Adviser’s comments about the substandard care of the PICC line, and the comment that there was no one trained to maintain it and advise the Ombudsman about its action as a result of this.
d) To remind nursing staff of the importance of:
• Weighing patients regularly where there are concerns relating to a patient’s dietary intake.
• Ensuring patients, where there is a concern about their nutritional intake, have regular nutritional risk assessments.
• All patients with an established laryngectomy stoma having access to relevant bibs which are worn when needed.
e) To consider if additional training is needed for nursing staff related to:
• Undertaking appropriate nutritional assessments for patients at nutritional risk.
• Assessment of a patient’s mental health, and the types of activities or interventions that can be used to improve mental wellbeing.