Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained about the care and treatment provided to her mother, Mrs B, during her admission to Wrexham Maelor Hospital and Ruthin Community Hospital between 16 February and 12 July 2021. Specifically, Mrs A complained that there was an unacceptable delay in obtaining a urine sample between 3 March and 7 March, which resulted in her mother requiring 3 courses of antibiotics.

Mrs A complained that Mrs B’s grade 3 pressure ulcer (an injury to the skin as a result of pressure or pressure in combination with shear (when the body moves over a surface and the skin is pulled causing stretching and tearing of the small blood vessels), graded with 4 being the most severe), identified on 25 March, should have been avoidable. She complained that Mrs B’s clostridium difficile infection (“C-Difficile” – a bacterial infection that can cause diarrhoea) was hospital acquired due to poor care and not due to Mrs B taking codeine as suggested by the Health Board. Mrs A also complained that there was a lack of appropriate discharge planning.

The investigation found that, whilst there was a delay in obtaining a urine sample, this did not cause harm to Mrs B and this complaint was not upheld. The investigation also found that the grade 3 pressure ulcer was avoidable, the C-Difficile infection was not due to taking codeine and there were delays in discharge planning. These complaints were upheld.

Betsi Cadwaladr University Health Board agreed to apologise to Mrs A for the failings identified. It also agreed to share the investigation report with relevant staff, remind staff of the importance of accurate record keeping, remind staff of the importance of proactive discharge planning in line with policy, and remind staff of the importance of following the pressure ulcer guidance including assessment, reporting and investigation. It also agreed to review its training of staff in regard to pressure ulcer assessment, management, reporting and investigating.