Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs X’s complaint related to the care and treatment that her late husband, Mr X, received from Betsi Cadwaladr University Health Board during his admissions to Glan Clwyd Hospital in early 2020. Specifically, Mrs X raised concerns about her husband’s wound care, as well as the failures by the Health Board to appropriately assess and manage his risk of falls, to meet his mobility needs and to adequately monitor and respond to both his weight loss and refusal to eat. Mrs X also raised concerns about her husband’s discharge from hospital on 9 March 2020. Lastly, Mrs X complained that there was a failure in infection control measures given that her husband had contracted 3 major infections while in hospital.

The Ombudsman concluded that the nursing care of Mr X’s foot wounds was of a reasonable standard. He also concluded that the decision to discharge Mr X on 9 March 2020 had been a reasonable one. As a result, the Ombudsman did not uphold these aspects of Mrs X’s complaint. However, the Ombudsman also found that, while there were records to demonstrate the assessment and monitoring of Mr X’s falls risk, it was unclear, due to a lack of documented evidence, whether the recommended interventions, or level of support or assistance by the correct number of staff to help Mr X mobilise, had been consistently completed or provided. The Ombudsman also found that the Health Board had failed to repeat the “Enhanced Care Risk Assessment”, and consider whether Mr X required more continuous supervision, at any point after 27 February despite him experiencing several falls. Similarly, with regards to the issue of Mr X’s oral and fluid intake, the investigation found that the records again did not consistently demonstrate how actions to improve his intake were achieved. Furthermore, it also appeared that there was a delay of over a week in completing a nutritional assessment using the Nutritional Risk Screening Tool during Mr X’s first admission, and that this assessment was subsequently scored incorrectly. This led to a delay in referring Mr X to the Dietitian. Finally, the investigation found that MRSA had been incorrectly included on Mr X’s death certificate as there was no evidence within the clinical records to indicate that Mr X actually had MRSA during his second admission to hospital. It was not, however, possible for the Ombudsman to determine whether or not appropriate infection control measures had been in place prior to Mr X contracting C. difficile and COVID-19respectively due to a lack of root cause analysis or post investigation reports. Therefore, the Ombudsman upheld these parts of Mrs X’s complaint.

The Ombudsman recommended that, within 1 month, the Health Board apologises to Mrs X and offers her a redress payment of £500 in recognition of the uncertainties and distress caused by the failings that he had identified. In addition, he recommended that the Health Board remind staff about the importance of sending stool samples for microbiological testing when indicated and of fully completing its “Clostridium difficile Integrated Care Pathway”. He also recommended that, within 6 months, the Health Board shares the findings of his report with nursing staff from the relevant wards and provide refresher training on the completion of documentation relating to falls and the Nutritional Risk Screening Tool. Lastly, he recommended that the Health Board review its practice in relation to post infection review investigation arrangements for healthcare associated infections. The Ombudsman also suggested an improvement action for the Health Board to consider voluntarily implementing. The Health Board agreed to implement the recommendations.