Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms A, an advocate acting on behalf of Mrs B, complained about the care and treatment provided to Mrs B’s late husband, Mr B, by Betsi Cadwaladr University Health Board. She specifically questioned whether clinical information provided to the Radiology Department in advance of a computerised tomography scan (“CT scan” – the use of X-rays and a computer to create an image of the inside of the body) was sufficiently detailed and whether the failure to identify a stomach ulcer via a CT scan in July 2021 impacted on Mr B’s prognosis. She questioned whether the actions taken post diagnosis regarding the exploration of treatment options were appropriate, and specifically whether the referrals, further investigations and multi-disciplinary team meetings were made, undertaken and held in an appropriate timeframe. She questioned whether Mr B should have been given treatment (palliative or other) between his diagnosis and death and whether communication regarding Mr B’s diagnosis, treatment options and prognosis was appropriate. Finally, she questioned whether the Health Board responded appropriately to concerns raised under the Putting Things Rights guidance.

The investigation found that the information sent to the Radiology Department for the initial CT scan was reasonable and this complaint was not upheld. While it was determined that Mr B’s death was unavoidable, it was found that earlier diagnosis could have been possible, which would have allowed Mr B the opportunity for treatment and may have extended his life by a short period. This complaint was upheld to this extent. The investigation also found that appropriate referrals and investigations were undertaken in a reasonable timeframe. There was a delay identified in the initial diagnostic pathway and this complaint was upheld to this extent. Mr B was offered reasonable treatment following his diagnosis, which he declined. Communication about his diagnosis, treatment and prognosis was also reasonable. These complaints were not upheld. Finally, the complaint handling by the Health Board was found to be delayed and confused. This complaint was upheld.

The Health Board agreed to apologise to Mrs B for the failings identified and make a financial redress payment to her of £1,200. It also agreed to share the report with relevant clinicians, consider developing guidelines for the investigation of patients referred with suspected cancer on the basis of non-specific symptoms at a relevant clinical governance meeting and review its complaint handling of the case to identify lessons that could be learned.