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Clinical treatment in hospital: Betsi Cadwaladr University Health Board

Report date



Clinical treatment in hospital


Upheld in whole or in part

Case ref number


Report type

Non-public interest report issued: complaint upheld

Relevant body

Betsi Cadwaladr University Health Board

Mrs Y complained about the care her late father, Mr Z, received whilst in hospital. The investigation considered whether Mr Z was given drinks during a period when he was nil by mouth, if Mr Z was appropriately treated for aspiration pneumonia and if Mr Z’s death certificate appropriately set out his cause of death. It also considered whether the Health Board had handled complaints made by Mrs Y appropriately.

The investigation found that records showed that Mr Z was given drinks during the period he was nil by mouth. Whilst the Health Board provided an explanation for this it was not possible to conclusively rule out that Mr Z was given drinks. The Ombudsman considered that Mr Z died of sepsis, which was not included on his death certificate. The investigation also found that Mrs Y was not kept informed of the progress of her complaint to the Heath Board and that the response she received did not address all the issues she had raised. As a result, the Ombudsman upheld these complaints. The investigation found that whilst there were entries in Mr Z’s notes referring to aspiration pneumonia, they were likely an error, as he was not displaying any symptoms at the time or receiving medication to treat it. As a result, the Ombudsman did not uphold this complaint.

As a result of these findings the Ombudsman recommended that the Health Board apologise to Mrs Y, offer her a redress payment of £750 for the failings identified in the investigation, remind nursing staff of the accurate recording on fluid balance charts and undertake a Mortality Review to consider the accuracy of Mr Z’s death certificate.