Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms C complained about the care and treatment her mother, Mrs A, received from the Health Board. Specifically, Ms C complained that Mrs A was unwell after her initial surgery on 4 June 2021 and was not fit to be discharged from Glan Clwyd Hospital. She also complained that Mrs A’s condition was not monitored adequately following her re-admittance to the Hospital on 5 June, prior to her second surgery on 8 June, and that communication with Mrs A’s family was poor throughout her admittance. Finally, Ms C was unhappy with the discharge planning on 24 June and follow-up care.

The investigation found that Mrs A’s assessment for her first discharge on 4 June did not reach a reasonable standard and that the information provided was confusing. Furthermore, although the discharge process on 24 June was broadly appropriate, the investigation found that follow-up tests were not arranged and no outpatient appointments were scheduled. The Ombudsman therefore upheld these points. However, the investigation found that Mrs A’s condition was monitored adequately following her second admission on 5 June. In regard to communication, provision of information to Mrs A’s family could have been better between Mrs A’s second admission and her surgery on 8 June. However, the Health Board had already introduced guidance since Mrs A’s experience that addressed this matter. The Ombudsman did not uphold these points.

The Ombudsman recommended that the Health Board should apologise to Mrs A and Ms C and ensure Mrs A receives the follow-up CT scan she needed. In addition, the Health Board should send nursing staff a copy of the Health Board’s Communication Guidance and share the relevant parts of this report with the staff involved in Mrs A’s nursing care at the time of her discharge on 4 June. Finally, it should review its discharge policies for inpatients having complex emergency abdominal surgery.