Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs C has complained about the care her late mother, Mrs A, received from Betsi Cadwaladr University Health Board (“the Health Board”) whilst she was a patient at Wrexham Maelor Hospital (“the Hospital”) until her death on 8 March 2022. The Ombudsman investigated the poor standard of end-of-life care Mrs A received at the Hospital and the inaccuracies in nursing record keeping and poor communication with the family about Mrs A’s end-of-life. Mrs C also complained that the Health Board’s complaint handling was not thorough or robust.

The investigation found that Mrs A’s end-of-life medical care was appropriate and reasonable. Mrs A’s concerns about the inaccuracies in the nursing records referring to her mother being sat up in bed on the day of her death, related to the management of Mrs A’s skin integrity which required moving and re-positioning. The Ombudsman was unable to definitively say whether Mrs A was assisted to sit up in bed to facilitate these skin integrity checks or sat up unaided, but in any event the skin checks were an integral part of her care.

The investigation found inadequate recording of Mrs A’s end-of-life nursing care, including the All Wales guidance document. This meant that Mrs A’s symptom control, and the concerns and preferences of her family about her end-of-life care were not properly documented. Although Mrs C had not raised any specific concerns to either the Health Board or the Ombudsman regarding this, nevertheless, these service failures meant that Mrs C was left with the impression that nursing staff were not aware that her mother was end-of-life. Given the uncertainty around symptom control we were unable to definitively conclude that Mrs A’s symptoms were effectively managed and to that extent only this aspect of Mrs C’s complaint was upheld

The Ombudsman was critical that communication with the family was not as effective as it could have been prior to 7 March 2022. This meant that the family were less prepared than they might have been when they were later informed of how gravely ill their mother was. The Ombudsman found shortcomings around the Health Board’s complaint handling and concluded that the Health Board’s response was not sufficiently robust. Given the uncertainty and the distress caused to Mrs C these aspects of her complaint were upheld. The Health Board was asked to apologise to Mrs C for the failures around communication and nursing record keeping issues 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 completion of documentation in line with relevant guidelines.