Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained about:
• The dosage of amitriptyline the Surgery prescribed for her late father, Mr B’s nerve pain in his leg.
• Her father’s management despite telephone calls to the Surgery reporting his hallucinations/confusion caused by his amitriptyline dosage.
• Her father’s management and care at Glan Clwyd Hospital in relation to a suspected bowel obstruction (“SBO”).
• Communication failings by both the Surgery and the Hospital.
• The Health Board’s complaint handling and complaint responses.

Broadly, the Ombudsman’s investigation did not uphold those parts of Mrs A’s complaint relating to the Surgery.
In relation to Mr B’s inpatient care the Ombudsman noted that Mr B, who had chronic vascular disease, underwent a specialised CT scan of his leg and abdomen. The CT scan and report showed the presence of a suspected SBO as an incidental finding, but this was not identified by the treating vascular clinician as the CT report was not read in its entirety. Mr B, who had started vomiting shortly after the scan, aspirated on vomit the following evening and suffered a cardiac arrest and died.

The Ombudsman’s investigation found that given the CT finding of a suspected SBO, as Mr B became symptomatic, treatment would have included fitting a nasogastric tube, as Mr B’s age and frailty placed him at higher risk of aspiration in the event of vomiting.
The Ombudsman found other clinical failings that also affected Mr B’s management and care.

The Ombudsman concluded that the injustice for Mrs A and the family was that they would have to live with the uncertainty that Mr B’s outcome could have been different. The Ombudsman upheld this part of Mrs A’s complaint.

As well as clinical communication failings, the Ombudsman found failings in the Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) process. He concluded that a DNACPR should have been discussed with Mr B on his admission and his views ascertained. The failure to do so, led to Mrs A being contacted when the resuscitation team became involved in her father’s management. The Ombudsman noted the invidious position Mrs A was placed in.

The Ombudsman also had concerns that resuscitation guidance concerning the minimum length of time resuscitation is carried out was not followed and that clinical considerations had not formed the basis for resuscitation being stopped.

The Ombudsman referred to the triggering of Article 8, the right to respect for private and family life with regard to Mr B’s SBO but especially the DNACPR.
As the communication failings had added to the ongoing and significant distress caused to Mrs A and the family and amounted to an injustice, this part of Mrs A complaint was upheld.

The Ombudsman found complaint handling was not as effective or robust as it should have been which meant Mrs A and the family had to continue to relive the distressing events surrounding their father’s death in order to obtain answers. This was an injustice for Mrs A and the family. This aspect of Mrs A’s complaint was upheld.

The Ombudsman’s recommendations included an apology, a time and trouble payment of £250 to Mrs A for complaint handling failings and that the Health Board should engage with Mrs A, on behalf of the family, in a process equivalent to Putting Things Right via its Legal and Risk Services Team.