Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr B complained about the care and treatment provided to his wife, Mrs B, who was admitted into hospital in December 2019 with back pain. Mrs B was discharged the next day. She was readmitted in March 2020 with worsening pain. Mrs B was diagnosed with cancer, and she sadly died in April.

The investigation found that notes about which of Mrs B’s symptoms were considered during her admission in December were unclear. This meant that it could not be established whether Mrs B was assessed in line with relevant guidance. However, it was not possible to establish either way if the cancer had been present in December or whether earlier treatment would have made any difference. This uncertainty caused Mr B an injustice and the complaint was, therefore, partly upheld. The investigation also found that the management, documentation and communication regarding 3 falls Mrs B suffered while in hospital were insufficient. It found that had measures been put in place following Mrs B’s first 2 falls, measures might have been put in place to reduce the likelihood of her third fall. It also found that there was insufficient evidence that Mr B was informed of Mrs B’s first 2 falls. This caused Mr B an injustice, and this complaint was upheld. The investigation found that the pain medication given to Mrs B, and the decision made not to treat her with radiotherapy initially due to her being confused and agitated, were both appropriate.

The Health Board agreed to apologise to Mr B for the failings identified, and remind relevant staff of the importance of pertinent aspects to the investigation (communication during patient handovers between hospitals, accurate completion of risk assessments and nursing documentation, including notifying the next of kin as soon as possible after a patient fall). It also agreed to advise all relevant staff to document in medical records exactly which red flags, or significant symptoms, are considered during diagnosis, and it agreed to provide training to relevant staff about in-patient falls and strategies to reduce their occurrence. Finally, it agreed to review its current falls documentation and consider if it is sufficient, or whether more documentation is needed.