Report Date

03/08/2024

Case Against

Betsi Cadwaladr University Health Board

Subject

Clinical treatment in hospital

Case Reference Number

202300378

Outcome

Not Upheld

Mr A complained about care provided by the Health Board for his vascular condition. The Ombudsman investigated his concerns that:

a) there was a failure to discuss all appropriate options for managing his vascular condition with him before referring him for surgery in January 2020
b) there was a failure to obtain his informed consent for vascular surgery, ensuring that he was fully aware of all significant risks associated with the procedure
c) the vascular service failed to provide appropriate post-operative care and follow up, particularly in response to his complaints of muscular pain and sexual dysfunction.

The Ombudsman did not uphold the complaints. The investigation found that the management of Mr A’s vascular condition was within the range of acceptable care. In particular, it was reasonable that the Consultant Vascular Surgeon responsible for Mr A’s care did not discuss or offer a less invasive surgical procedure in January 2020.

Taking all the evidence into account, the investigation found, on a balance of probabilities, that it was more likely than not that the treating clinicians shared appropriate information with Mr A about the relevant risks associated with the surgery. These included the complications which he later complained about, but maintained he had not been made aware of before his operation. The Ombudsman was concerned that Mr A had not been provided with copies of relevant consent forms. While this was not a sufficiently serious failing to uphold the complaint, it was a missed opportunity to ensure that he was able to take away the document which detailed the relevant risks before his operation. This may have given him the opportunity to consider those risks in greater detail. The Ombudsman therefore invited the Health Board to share a copy of the final report with the Consultant Vascular Surgeon and to remind all surgical clinicians at Ysbyty Glan Clwyd of the importance of ensuring that patients have fully understood any information they are given about the risks associated with surgery. The investigation also found that the follow up and monitoring provided after Mr A’s operation was within the range of acceptable practice.