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 management her father, Mr B received at Wrexham Maelor Hospital (“the Hospital”) managed by Betsi Cadwaladr University Health Board (“the Health Board”). Mrs A complained that the Hospital’s Vascular Team, failed to provide appropriate and timely treatment following Mr B’s deterioration between June and October 2021. Mrs A complained that the Consultant Physician in Diabetes and Endocrinology and the Consultant Renal Physician’s decision on 13 May to reduce the dosage of her father’s water management medication caused increased swelling in his lower body and legs and put pressure on his already restricted blood flow. Mrs A said that her father was overdosed with warfarin (an anticlotting medication) causing internal bleeding. Finally, she said that there was a delay in complaint handling and a failure to address the erroneous communication by the Consultant Cardiologist with her father and the family. Sadly, Mr B later died in hospital on 5 November.

The Ombudsman’s investigation found that the vascular care and management Mr B received was appropriate and did not uphold this aspect of Mrs A’s complaint. The investigation concluded that if reducing water management tablets was to prevent further kidney deterioration then this would be reasonable. However, the Ombudsman was critical that this was not communicated to Mr B or his family which caused them distress. This aspect of Mrs A’s complaint was upheld to a limited extent.

The investigation found clinical shortcomings around the management / monitoring of Mr B’s warfarin dosage. Whilst the Ombudsman was satisfied that Mr B’s eventual outcome would not have altered, the shortcoming in his care led to additional pain and suffering and caused the family distress. This aspect of Mrs A’s complaint was upheld. The investigation also concluded that 1 year to provide a complaint response was excessive and the failure to

address Mrs A’s concerns about communication was unreasonable. This added to Mrs A and her family’s distress and caused an injustice to them. This part of Mrs A’s complaint was upheld.

The Ombudsman recommended that the Health Board apologise for the failings identified and pay Mrs A £250 for the poor complaint handling. The Health Board was asked to remind clinicians of the importance of informing patients of changes in their medication. The Health Board was also asked to remind staff of the importance of monitoring blood tests before adjusting or prescribing warfarin in high bleeding risk patients, taking into account other medications.