Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs X complained on behalf of her late mother, Mrs Y, about the care and treatment provided to Mrs Y by the Health Board in October 2019. Specifically, Mrs X complained that the Health Board unreasonably placed Mrs Y on a standard surgical ward following surgery on 3 October, failed to undertake appropriate observations of Mrs Y, failed to prescribe and administer appropriate medications to Mrs Y, failed to correctly insert, monitor and maintain a nasogastric tube (“NG tube”) between 5 and 14 October, and failed to ensure that Mrs Y and her environment were provided with an appropriate standard of hygiene. Mrs X also complained that the Health Board did not handle her complaint properly.

The complaint that Mrs Y was placed on a standard surgical ward unreasonably was upheld, as it was noted that she had been identified as needing to be cared for in HDU after her surgery. It was found that Mrs Y had suffered injustice because the care she received on the ward was not in line with what she had been led to expect, rather than because there was a link between her care on the standard ward and her deterioration. In relation to the complaint that Mrs Y’s observations were not undertaken appropriately, the complaint was not upheld. However, it was noted that the Health Board had reviewed staffing levels on the ward and had increased them. The investigation found that Mrs Y’s clinicians were not informed that she had been unable to complete a prescription which she had been taking on admission to hospital, that she was prescribed a drug for 7 days which should only have been used for 5, and a prescription for Tazocin was written but not administered on 13 October before being cancelled, only to be prescribed again on 14 October. It also found that, although Tazocin was prescribed at 14.15 on 14 October, it was not administered, as Mrs Y had died by 23.30 when the nurse tried to administer it. This caused an injustice to Mrs Y, because, at the moment of her death, her daughter Mrs X was “chasing staff” to administer Tazocin, not with Mrs Y. The complaint was upheld.

In relation to the complaint about the NG tube, the investigation found that fitting the NG tube was the best course of action for Mrs Y, who would have been at greater risk had it not been fitted. It noted that the NG tube had displaced at times, which would have been uncomfortable, and its output was not properly documented on occasions. Mrs X complained that there were occasions when the NG tube was not emptied, and this may have caused Mrs Y to aspirate, however the investigation found that Mrs Y already had an element of aspiration before the NG tube was inserted. While it accepted that the NG tube was uncomfortable and did on occasions displace, the complaint was not upheld. The complaint regarding the standard of hygiene maintained on the ward was upheld on the basis that the Health Board did not dispute Mrs X’s concerns about the matter. It was noted that this would have been very distressing for Mrs Y, who was described as a fastidious person. It was noted that there was no ward housekeeper in post at the time of these events, which had been addressed.

The complaint response Mrs X received said that the Consultant who reviewed Mrs Y after her surgery thought she looked well and could be admitted to a standard ward. It made no reference to the fact that the HDU was full, which was poor complaint handling practice. For this reason, the complaint was upheld.

The Health Board agreed to apologise to Mrs X and pay her £1,000 for the identified failings. It also agreed to remind staff that where a HDU bed was not available post-operatively, then a discussion around continuing with surgery should be held with the patient, of the importance of recording when prescription medication is not administered, with reasons, and to ensure that correct documentation is completed when antibiotics are prescribed or cancelled.