Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms A, who lives in England, complained about her Emergency Department (“ED”) care and treatment from Betsi Cadwaladr University Health Board’s (“the Health Board”) Wrexham Maelor Hospital on 14 September 2019. She was dissatisfied with the handling of her complaint and the robustness of the response which extended to the GP Out of Hours (“GPOOH”) Service.

The Ombudsman’s investigation found that there were areas of Ms A’s care that could have been managed better, for example, her pain assessment. However, based on the evidence, the Ombudsman concluded that at the time of Ms A’s ED triage, based on her clinical presentation, there was no indication to suggest that Ms A was at risk of sepsis.

Administratively, as the Health Board had done, the Ombudsman found documentation failings on the part of the ED Triage Nurse which contributed to a lack of clarity regarding Ms A’s care pathway causing Ms A an injustice. To this limited extent only the Ombudsman upheld this part of Ms A’s complaint.

In relation to complaint handling, the Ombudsman concluded that communication was not as effective as it should have been and this was coupled with an excessive delay in the Health Board responding to Ms A’s complaint with no convincing evidence on the complaint file of why this should have been the case. That said, the Ombudsman found that broadly the Health Board’s complaint response was robust and the Health Board had acknowledged areas for improvement by its GPOOH Service when dealing with patients in England accessing care in Wales and had taken steps to address this. The Ombudsman considered that the shortcomings in complaint handling and the inconvenience caused to Ms A amounted to an injustice. To that extent he upheld this part of Ms A’s complaint.

The Ombudsman’s recommendations included the Health Board apologising to Ms A, making a redress payment of £250 for the inconvenience caused to her from the handling of her complaint, considering implementing a policy to cover situations where patients are redirected form the ED to its primary care services and reviewing its sepsis documentation.