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Clinical treatment in hospital: Betsi Cadwaladr University Health Board

Report date



Clinical treatment in hospital


Not Upheld

Case ref number


Report type

Non-public interest report issued: complaint not upheld

Relevant body

Betsi Cadwaladr University Health Board

Ms B made a complaint about the nursing care provided to her late aunt, Mrs C, by Betsi Cadwaladr University Health Board, while she was in hospital between 28 February and 25 April 2022. The investigation considered whether appropriate care and treatment were provided to prevent Mrs C from developing pressure sores, and whether her pressure sores contributed to the decline in her health.

The investigation also considered whether appropriate care and monitoring were provided in relation to Mrs C’s nutritional needs while she was in hospital.

The Ombudsman determined that whilst there were some concerns relating to how often care was provided on one ward, this did not result in the development of any pressure sores. There were no concerns regarding the care provided on a subsequent ward, when a pressure sore to Mrs C’s sacrum (the area at the base of the spine) developed. This sore was highly likely to have been unavoidable. There was no indication that the deterioration of Mrs C’s pressure sore after her discharge, or any associated decline in her health, was a result of failings by the hospital.

The Ombudsman also found, in relation to Mrs C’s nutritional needs, that appropriate care, monitoring and input was provided. Although failings in record keeping were identified, it was determined that that this did not prevent the appropriate interventions taking place for Mrs C. The complaint was not upheld.