Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr X complained about the care that his late wife, Mrs X, received from Betsi Cadwaladr University Health Board (“the Health Board”) during her admission to Glan Clwyd Hospital in October 2020. Specifically, he complained that his wife was not given intravenous (“IV”) fluids after she had been moved between wards. Mr X also complained that there was a delay in prescribing Fortisip (a liquid nutritional supplement) for his wife as this was only done after he had made a request to nursing staff.

The investigation found that there was evidence of a cannula (a thin tube inserted into a vein to administer medication or fluids) being inserted after Mrs X had been transferred between wards. Furthermore, it did not identify any failings in the management of her fluid intake in general. As a result, the Ombudsman did not uphold this aspect of Mr X’s complaint. However, the Ombudsman also found that missing food charts within Mrs X’s records meant that there was a possibility that Mrs X should have been given Fortisip some 10 days earlier than when she was actually given it. He also found that there was no care plan for Mrs X included in the records, which was not in accordance with relevant guidance. The Ombudsman considered the uncertainty arising from the inability to say for certain whether Fortisip should have been given at an earlier stage to represent an injustice to Mr X. As a result, the Ombudsman upheld this part of the complaint.

The Ombudsman recommended that the Health Board apologise to Mr X and remind all relevant staff of the importance of both maintaining complete food charts and ensuring that patients with a moderate or high risk of malnutrition have a care plan in place. He also recommended that the Health Board undertake an audit in relation to the completion of patients’ food charts on the relevant wards and take appropriate action to address any shortcomings that are identified. The Health Board agreed to implement these recommendations.