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Clinical treatment in hospital: Betsi Cadwaladr University Health Board

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Clinical treatment in hospital


Upheld in whole or in part

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Non-public interest report issued: complaint upheld

Relevant body

Betsi Cadwaladr University Health Board

Mrs Y raised concerns about the gastroenterology care and treatment provided to Mr X. Specifically she raised concerns about the investigations that took place, and the urgency with which these were done. She complained that this resulted in a delay in the eventual diagnosis of stomach cancer.

The Ombudsman found that the investigations which were done were appropriate. The Ombudsman found no evidence to indicate that the endoscopy or biopsy process did not follow relevant guidelines or accepted clinical practice. However, the Ombudsman noted that a referral for manometry testing went astray and, whilst this did not directly impact on the cancer diagnosis, this created uncertainty as to whether an earlier consultant review may have happened. There was also a failure to communicate effectively with Mr X that cancer remained a possibility despite the negative biopsy result, thereby resulting in the subsequent diagnosis being a shock. Both these aspects of the complaint were upheld.

The Health Board agreed to provide an apology to and offer a meeting with Mr X’s family, in addition to reflection and learning by the clinician involved.