Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

Ms B complained about the care and treatment her late daughter, Ms C, received from Betsi Cadwaladr University Health Board(“the Health Board”) on 4 February 2019. In particular, Ms B complained that the Health Board failed to provide Ms C with appropriate care and treatment, failed to undertake appropriate tests and investigations, including specifically, a brain scan and inappropriately discharged Ms C home from the ED. In response to evidence gathered during the investigation, the Ombudsman used his “own initiative” investigation power under Section 4 of the Public Services Ombudsman (Wales) Act 2019 to extend the investigation to consider, as an additional complaint, whether Ms C received appropriate care and treatment from the Health Board’s Endocrinology Department.

The investigation also found that Ms B received appropriate management from the Endocrinology Department. While in retrospect the endocrinologist could have considered whether there was an alternative cause for Ms C’s symptoms, his management plan was appropriate. Accordingly, the Ombudsman did not uphold this element of Ms B’s complaint.

The Ombudsman recommended that the Health Board should apologise to Ms B and make a payment to her of £750 in respect of the failings identified. He also recommended that the Health Board should share the report with the relevant clinical staff and confirm that the report has been used for critical reflection. Finally, the Ombudsman recommended that the Health board should remind the clinicians in its ED of the importance of undertaking full neurological examinations.