Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Voluntary settlement

Mr X’s complaint to the Ombudsman was in relation to a number of matters concerning his late mother, Mrs Y.
Mrs Y’s care and complaint handling

Mr X complained about aspects of his late mother, Mrs Y’s, care while she was an inpatient at the Hergest Unit between July and September 2013. In particular, he complained that the Health Board did not:
• “Section” Mrs Y when she was admitted.
• Manage her nutritional care and falls risk appropriately.
• Address a ligature risk posed by the Unit’s blinds.
• Tackle a potential safeguarding issue raised by a large bruise on Mrs Y’s forehead.
• Manage her discharge from the Unit to a care home properly.

Mr X also complained about the way in which his complaint to the Health Board had been handled.
The Ombudsman began an investigation of Mr X’s complaints about Mrs Y’s care and the handling of his complaint. During the investigation he identified the following failings in Mrs Y’s care:

• There was a failure to follow national guidelines for the prevention of malnutrition and no clear evidence that Mrs Y’s nutritional needs were appropriately provided for. The malnutrition form was incomplete, brief and poorly written; food charts were incomplete; there appeared to have been no nutrition screening and the national guidelines (the MUST tool) were not used.
• As Mrs Y was prone to falls at home before she was admitted to the Unit, she should have had a falls assessment on admission and after a potential fall on 30 August. She did not have such an assessment until 8, 9 and 10 September, and even then the records were brief and incomplete.
• No patient safety incident report was completed in relation to Mrs Y’s bruising on 22 September, and a more robust falls assessment should have been carried out at this point.
• There was no overall comprehensive assessment to inform an overall care plan for Mrs Y; although there were some standalone plans, they were not goal orientated or focused on the outcome of any interventions. Such records as existed were often incomplete and brief, and there was no evidence Mrs Y was involved in developing her own care plan with the ward staff.

With regard to complaint handling, the Ombudsman found that changes in the staff members dealing with the internal complaints investigation were not adequately explained to Mr X and this led to a loss of trust on Mr X’s part in the process. The limited remit of the subsequent external investigation was a missed opportunity for the concerns to be independently investigated.

Assessment of Mrs Y’s eligibility for NHS Funded Continuing Health Care (“CHC”)

In 2016 the Health Board commenced a retrospective review of whether Mrs Y had been eligible for NHS Funded Continuing Health Care (“CHC”) during the period 1 October 2013 – 19 June 2016. Mr X was unwilling to accept an initial finding of partial eligibility because he was concerned that the process had been compromised due to inaccuracies in the records of his mother’s care at the Hergest Unit before her discharge to a care home. In July 2019 an Independent Review Panel (“the First IRP”) found no eligibility for CHC.

Mr X complained to the Ombudsman that the retrospective review process had been unfair because the Health Board had failed to comply with aspects of the relevant Welsh Government guidance document “Continuing NHS Healthcare: The National Framework for Implementation in Wales” (“the National Framework”). Specifically, he said that:
• the Health Board had deviated from the expected process by convening the First IRP without first holding a negotiation meeting;
• the First IRP had not been provided with documents containing information relevant to his mother’s care needs;
• he had not been given sufficient opportunities to represent his concerns to the First IRP.
The National Framework states at paragraph A5.13 that “the panel should have access to any existing documentation, which is relevant.” In response to the Ombudsman’s enquiries, the Health Board confirmed that 2 documents relating to a multi-disciplinary meeting on 31 May 2016, had not been considered by the First IRP. The Ombudsman was concerned that the confirmed omission of relevant information indicated that the First IRP had not been held in full compliance with the National Framework. In order to resolve the aspect of Mr X’s complaint relating to the CHC process, the Health Board agreed to carry out a thorough search for relevant information which had not been provided to the First IRP and to arrange for a different health board to convene a new IRP (“the Second IRP”) to reconsider Mrs Y’s eligibility for CHC.

During the process of preparing arrangements for the Second IRP (which became protracted and complex), Mr X raised further concerns with the Ombudsman that additional relevant documentation existed which had not been included for consideration by the Second IRP. He also repeated his concerns that problems with the records from the Hergest Unit would compromise the process. Taking these issues together, it was clear that he had lost trust and confidence in the ability of the Second IRP to reach fair and robust findings.

The Ombudsman reconsidered the agreed settlement arrangements in the light of Mr X’s comments. Having further assessed the records relating to the Hergest Unit, the Ombudsman was concerned that they did not provide holly reliable evidence of Mrs Y’s care needs immediately prior to the start of the claim period, because they appeared incomplete, were in places contradictory and appeared to have been altered.
Taking this into account, and having regard for the lack of reliable records which were available, the Ombudsman reached the view that a Second IRP could not be carried out soundly. On the basis of the particular and exceptional circumstances of the complaint, and having regard for Mr X’s loss of trust and confidence in the process generally and the passage of time during which the matter had remained unresolved, the Ombudsman proposed a payment of financial redress in settlement of this aspect of the complaint.

The Health Board agreed to carry out the following actions in settlement of all elements of Mr X’s complaint:
1) Pay Mr X a sum which would have been payable to him had the CHC funding process been conducted appropriately and a sum of approximately 40% eligibility for funding been found.
2) Pay Mr X the sum of £2,500 in recognition of the injustice caused as a result of the failings in the care and treatment provided to Mrs Y.
3) Pay Mr X the sum of £2,500 in recognition of the poor complaint handling and injustice caused to him by that.
4) Provide Mr X with a fulsome apology from the Chief Executive for the failings identified and the injustice caused to him and his family.
5) Review national guidelines on malnutrition screening and ensure that its local policy meets those guidelines. If no such local policy exists, the Health Board will implement a fresh policy which meets the guidelines.
6) Review its process for falls risk assessments to ensure that it meets national guidelines.
7) Review its standards in care planning and ensure that it has such a system in place.

8) Review its process for reporting patient safety incident reports and ensure that staff record incidents on its “incidents system”.
9) Provide Mr X with an opportunity to engage with an appropriate staff member with responsibility for elderly patients’ dementia care in order to share learning from the complaints to improve future services.

The actions referred to in 1-4 above were to be completed within 3 weeks of Mr X confirming to the Health Board that he accepts the settlement, and that in 9 within 2 months of such confirmation. The actions set out in 5-8 above were to be completed within 4 months of the date of the settlement.

The Ombudsman considered that the actions the Health Board agreed to take were reasonable, and therefore regarded the matter as settled.