Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr A complained about the care and treatment that was provided to his late mother (Mrs B). He complained that Mrs B should not have been kept on a COVID-19 holding ward, that the medication prescribed to treat her fluid retention was inappropriate and that antibiotics should have been prescribed. In addition, he complained that Mrs B should not have been operating on whilst she was suffering from fluid retention. Furthermore, he complained that appropriate DNACPR consent was not obtained from Mrs B, that the family were not consulted about this nor where they informed of her condition and prognosis as an inpatient. Finally, Mr A complained about the factual accuracy of the Health Board’s complaint response.

The investigation found that as it was suspected that Mrs B was suffering from COVID-19 it was appropriate that she was placed on a holding ward pending a negative test result. The medication prescribed and administered to treat her fluid retention was within standard practice. Mrs B was prescribed antibiotics during her admission. The investigation found on balance, the benefit of surgery outweighed further delay for optimisation of heart failure treatment. The timing of the operation was appropriate, and Mrs B was provided intraoperative care and treatment to an acceptable standard. Consequently, these aspects of Mr A’s complaint were not upheld.

The contemporaneous clinical notes in relation to the discussion held with Mrs B around DNACPR were sparse, the deficiency hindered the investigation and this aspect of Mr A’s complaint could not be determined.

There was a short delay in the family being informed of the DNACPR decision however Mr A was made aware before Mrs B died and therefore no injustice was caused as a consequence; this aspect of Mr A’s complaint was not upheld.

The investigation recognised that Mrs B was a patient during the early days of the COVID-19 pandemic, it was an unprecedented time and resources were stretched. At this juncture, visiting was restricted and so relatives were dependent on staff to keep them updated regarding the clinical status of their loved ones. The investigation concluded that the level of communication was not appropriate and this aspect of Mr A’s complaint was upheld.

With regard to the Heath Board’s complaint response, there was a factual inaccuracy in relation to the timing of a Cardiology review and therefore this aspect of Mr A’s complaint was upheld.

The investigation also identified several examples of poor record keeping by the clinical staff involved in Mrs B’s care. As this was not a specific head of complaint no formal recommendations could be made but the Health Board agreed to implement specific improvement actions.

The Health Board agreed to apologise to Mr A for the failures identified and prepare guidance on the level of communication expected between staff and relatives in circumstances where by visitation is suspended and/or restricted.