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 between 21 January 2018 and 13 November 2019, Betsi Cadwaladr University Health Board (“the Health Board”) failed to appropriately monitor and investigate his rising PSA level (prostate specific antigen – a PSA test is not a specific test for prostate cancer but a marker of cancer risk; an elevated PSA level may indicate prostate cancer). In September 2019, investigations revealed evidence of metastatic prostate cancer (a cancer that has spread from the primary site). Mr Y believed that there was a delay in the diagnosis, and that he should have been offered a magnetic resonance imaging (MRI) scan (a type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body) as part of the investigations into his rising PSA level, which may have resulted in earlier diagnosis.

The Ombudsman found that between January 2018 and March 2019, Mr Y received appropriate clinical care and investigations. He was also satisfied that there was no clinical indication for an MRI scan. However, the Ombudsman found that, despite a PSA of 66 in March 2019, there was a failure to recognise the significance of this increase and as a result, there was a delay of 6 months before Mr Y received a diagnosis and appropriate treatment. The Ombudsman was satisfied that the failure to identify the significance of the elevated PSA was a service failure which led to an injustice to Mr Y as his treatment was delayed by 6 months.

The Health Board agreed to apologise to Mr Y for the identified failing, to share the report with one of the treating consultants for reflection and learning, and to review its use of locum consultants.