Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Public Interest Report

Ms D complained about the care and treatment her sister, Ms A, received from Wrexham Maelor Hospital (“the Hospital”) in July 2022 . Ms A had several medical conditions, including epilepsy (a condition which causes seizures), cerebral palsy (a condition that affects movement and co-ordination) and learning disabilities. She lived in a nursing home, had limited communication, and required 24 hour care and support.

The Ombudsman found that the Health Board’s management of Ms A’s personal care needs, her nutrition and hydration, and communication with her fell below an adequate standard. On the occasions that the Learning Disability (“LD”) team and Ms A’s family were not present to assist, the nursing care on the ward fell short of acceptable standards, especially at weekends and overnight. No additional staff were brought in to support care delivery. There was no person-centred nursing care plan setting out the care objectives and adjustments that were needed to provide Ms A with effective care. This meant that staff did not fully understand her needs.

The Ombudsman also found that there were multiple occasions when Ms A’s pain was identified by her family and the LD team, but it was unclear whether nursing staff were consistently able to identify pain, as the assessment tool used was not adapted for Ms A’s particular needs. This failure meant that Ms A suffered unnecessarily.

The Ombudsman found that there was a poor standard of record keeping in relation to Ms A’s seizures. This was dangerous and represented a poor level of care. It was unclear whether nursing staff recognised Ms A’s seizures themselves, and had her family not been present, it is likely that many of her seizures would have gone unnoticed. Administration of medication was also found to be inadequate. Poor compliance with anti-seizure medication may have contributed to the increase in Ms A’s seizure activity.

The Ombudsman made a number of recommendations, which the Health Board accepted. These included:

· An apology to Ms D, on behalf of Ms A for the failings identified, and for Ms D having to pursue her complaint.

· A review of care planning practices on the ward to ensure care plans are embedded into basic care.

· A review of a sample of person-centred care plans to ensure they include any adjustments to meet a patient’s individual needs.

· Implementation of a regular ward audit of nursing documentation, to include care plans and seizure charts.

· A review of the approach to pain assessment for people with learning disabilities to ensure adjustments and appropriate tools are used.

· Providing training to ward staff in respect of mental capacity and best interest decision making.

· Engagement with the social services departments of all local authorities within the Health Board area to implement a joint care pathway to ensure safe staffing levels when vulnerable people with additional needs are admitted from care/nursing homes.

· Providing confirmation that its Patient Safety and Experience Committee will monitor compliance with ongoing actions to satisfy the Ombudsman’s recommendations.