Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms X complained about the care and treatment her late mother, Mrs Y, received from Betsi Cadwaladr University Health Board (“the Health Board”). We investigated whether Mrs Y’s treatment from June 2022, when symptoms suggesting a recurrence of rectal cancer were identified, was appropriate and timely, including whether she should have been referred earlier to an oncologist. We also investigated whether Mrs Y was appropriately triaged and treated in the Emergency Department (“the ED”) on her admissions in August, including whether pain relief was appropriately supplied.

We found that the investigations which Mrs Y underwent after June 2022 were appropriate, as was her referral to a specialist cancer hospital outside the Health Board’s area. However, the overall time before Mrs Y was seen by a consultant oncologist was too long and led to Mrs Y being unaware of her treatment plan for longer than she should have been. This was an injustice to her, and this part of the complaint was upheld. However, sadly, the outcome would not have been different if she had been seen by the consultant oncologist sooner, as her disease was already advanced by June.

In relation to Mrs Y’s ED admittances, in terms of a specific concern Ms X had raised about a delay in replacing Mrs Y’s syringe driver on 1 admission, we found that although there was a short delay, Mrs Y was given intravenous morphine until it was set up, and this was appropriate. In terms of her admittances overall, we found that while Mrs Y was appropriately triaged on each of her admittances to the ED, this was not always as soon after her arrival as she should have been, and she was not seen within the time recommended for the triage category she had been allocated. While Mrs Y was offered pain relief each time, this was not always as promptly as she should have been owing to the wait for triage. In addition, the effectiveness of the pain relief was not checked. This complaint was therefore upheld.

We recommended that the Health Board should apologise to Ms X for the failings identified and should consider the feasibility of minimising chemotherapy/support service referral waiting times for patients like Mrs Y, and feedback to the Ombudsman. We also recommended that it should review the comments made by the Ombudsman’s professional adviser in relation to the wider issues regarding staffing levels, not just in relation to night shifts in the ED, and feedback any improvements it has considered in relation to this. Finally, we recommended that all ED clinical staff should be reminded of the relevant guidance issued by the Royal College of Emergency Medicine concerning the importance of providing and assessing effective pain relief.