Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs G complained that, as a result of failings in the end-of-life care that her late husband, Mr G, received at Ysbyty Glan Clwyd, his deterioration and death from pneumonia and sepsis was acutely painful and distressing. Mrs G complained that, for the last 2 days of his life, clinicians failed to identify that a syringe driver was faulty. Consequently, Mr G did not receive adequate pain control or other essential medication during this time and suffered a painful death.

The Ombudsman upheld the complaint. He found that the syringe driver was not faulty but that its intermittent alarming was caused by an occlusion (or blockage) which prevented it from delivering medication for the last 17 hours of Mr G’s life. The Ombudsman found that this problem was not understood by the nurses caring for Mr G who failed to escalate the matter to a senior nurse or technician and failed to monitor the performance of the machine in accordance with established procedure. Although Mr G did not receive prescribed morphine, the Ombudsman found no evidence that, in his final hours, he suffered pain or distress. However, the absence of clinical indicators of pain does not preclude this possibility and the uncertainty surrounding this question remains a source of distress for Mrs G and, in its own right, an injustice.

The Ombudsman also found that an attempt to discharge Mr G was reasonable and that it failed due to the unfortunate circumstance that he aspirated fluid into his lung and developed an infection. Finally, the Ombudsman found that, in responding to Mrs G’s complaint, the Health Board failed to examine the syringe-driver event-log which detailed the behaviour of the machine. As a result the Health Board’s account of the events in question was inaccurate and misleading.

The Ombudsman recommended that the Health Board:

• Provides Mrs G with a fulsome written apology for the clinical and complaint investigation failings identified in the report and makes a redress payment to her of £750 in recognition of the distress these failings gave rise to

• Ensures that the report is discussed with the relevant ward team and its contents reflected upon

• Develops an Action Plan to address the following issues:

• Monitoring and recording the use of syringe drivers (in accordance with RMM Guidance).

• Revision of safe and secure handling of medicines policy and the recording of controlled drugs (with reference to the RPS Guidelines).

• The recording (dating and timing) of significant clinical and communication events in nursing records (with reference to NMC Guidelines).

• Revision of the assessment of pain in older people and in end-of-life care.

The Health Board agreed to implement these recommendations.