Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

We investigated a complaint made by Mrs B about the care and treatment her late mother, Mrs A, received from Betsi Cadwaladr University Health Board. She complained that nursing care and treatment received by Mrs A did not reach an appropriate standard in relation to her personal care and continence needs, nutrition intake records and weight monitoring, and hospital discharge communication with Mrs A’s care home. She also complained that Mrs A was not provided with treatment for diarrhoea within a reasonable timescale.

The complaints about the discharge communication and Mrs A’s treatment for diarrhoea were not upheld as there were both found to have been dealt with adequately. However, the Ombudsman found that the frequency of Mrs A’s personal and continence care was not sufficient, resulting in a deterioration of the condition of her skin. Mrs A’s nutritional care was also inadequate – she did not receive the appropriate level of input or action to address her declining weight. The Health Board failed to meet an appropriate standard of care in those respects and, accordingly, those complaint points relating to nursing care were upheld.

The Ombudsman recommended that the Health Board apologise for the failings identified and remind nursing staff of the importance of accurate completion and maintenance of documentation and risk assessment tools so that appropriate actions can be determined. She also recommended that the Health Board undertake an audit of nutrition risk assessment tool documentation on the relevant wards and to address shortcomings, if identified.