Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr Y complained that the Health Board:

(a) Failed to report on an X-ray taken at his wife’s (Mrs Y) attendance at Glan Clwyd Hospital Emergency Department (“ED”) on 26 October 2019. He said this delayed appropriate medical management resulting in a further ED admission on 4 November. Had Mrs Y been admitted for further investigations on 26 October, he said the diagnosis of lung cancer and brain metastases would have been reached sooner and Mrs Y would have received treatment that would have prevented her stroke (the reason for her 4 November admission).

(b) Discussed Mrs Y’s prognosis/do not attempt cardiopulmonary resuscitation decision with her on 26 November without a family member in attendance, which Mr Y said was contrary to Mrs Y’s wishes as documented in her records on 20 November.

His complaint about the appropriateness of the decision to transfer Mrs Y to another hospital for blood tests in November 2019 was concluded by early resolution during the investigation.

The Ombudsman upheld complaint (a). He found that there was a failure to report the X-ray which delayed earlier diagnosis and clinical input. However, taking into account professional advice, he found that this would not have prevented Mrs Y’s weakness/symptoms she presented with on 4 November; these were due to the spread of cancer to her brain.

The Ombudsman did not uphold complaint (b); there were no references in Mrs Y’s records to support the complaint.

The Health Board agreed to provide an apology and take action to ensure that ED management of radiological investigations were in line with relevant guidance.