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 that her baby son, Y, did not receive an appropriate and reasonable diagnosis and/or treatment from Betsi Cadwaladr University Health Board (“the Health Board”) between January and March 2019. Mrs X also complained that communication between family members and staff at the Health Board was poor and did not take into consideration Mrs X’s concerns.

The complaint that Y did not receive an appropriate diagnosis was not upheld, on the basis that Y’s condition was a very unusual one and it was diagnosed within 2 months of his birth. The investigation found that Y should have been seen by a more senior doctor earlier, but that even if he had been, the correct diagnosis may not have been made, and in any event, Y would still have required surgery.

The investigation upheld Mrs X’s complaint about communication, on the basis that Y’s GP had expressed concerns to the Health Board, that staff within the Health Board re-referred Y, and Mrs X raised repeated concerns about Y’s condition. This caused an injustice to Y and Mrs X, who will not know whether, if Y had seen a more senior clinician, his condition may have been addressed more promptly. This complaint was also upheld on the basis that Mrs X was not kept informed of plans to transport Y to a children’s hospital, or on what basis the transfer was to take place (not as an emergency) leading her to unnecessarily believe that Y’s life was in danger.

The Ombudsman recommended that the Health Board should apologise to Mrs X, and confirm to her what it has done to ensure its policy on consultant review of frequent ward attenders is implemented, and what it has done to provide guidance to staff in relation to documenting evidence, such as photographs, provided by parents, within 3 months.