Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr X was diagnosed with alcohol induced dementia, he was 80 years old, he lived alone and was attended to daily by carers. On 16 June 2020 Mr X was found by his carer on the floor, an ambulance was called, and he was admitted to Ysbyty Glan Clwyd. On 29 June Mr X was discharged home, the next day the District Nurse noted pressure ulcer’s to Mr X’s back. An ambulance was called and Mr X was readmitted. On 15 July Mr X was transferred to a Community Hospital and sadly died on 20 July. Mr Y and Ms Z complained whether their late father’s discharge from hospital was reasonable.

The Ombudsman found that although Mr X’s pressure ulcers were inconsistently reported and classified, their prevention and management was reasonable. It was unlikely that these failings impacted on the outcome of Mr X’s treatment. The Ombudsman invited Betsi Cadwaladr University Health Board (“the Health Board”) to reflect on these issues and identify any learning from this reflection.

The Ombudsman found that whilst Mr X’s discharge summary had not recorded key issues, his discharge was reasonable. He found that Mr X should have been referred to the District Nursing Service before he was discharged and on this basis the complaint was upheld.

The Health Board agreed to implement the Ombudsman’s recommendations within 1 month, to apologise to Mr Y and Ms Z for the failing, inform the Ombudsman its proposal to measure compliance for a discharge checklist and within 3 months to provide evidence that nursing staff have appropriate knowledge to make a district nursing referral.