Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Miss A complained about the nursing care and treatment provided to her late mother, Mrs B. In particular she complained that the Health Board failed to provide an adequate standard of nursing care to her mother following surgery to her ankle, and that this failure led to her developing a pressure sore along with a general decline in her health. She also complained that her mother was moved between wards an excessive number of times without paying due regard to her mother’s mental health, including transferring her to another hospital without an appropriate pre-transfer assessment.

The Ombudsman’s investigation found that had appropriate clinical guidance been followed, the pressure sore on Mrs B’s left heel could have been avoided and that the pressure sore had an adverse impact on her recovery. This aspect of the complaint was therefore upheld. The investigation found that whilst ward moves were unfortunately necessary during Mrs B’s admission, communication with the family regarding the changes was poor and caused avoidable distress. The complaint was upheld.

The Ombudsman recommended that, within 1 month, the Health Board should issue a written apology to Miss A and make a redress payment to her of £250 in recognition of the avoidable distress she incurred. He also recommended that within 3 months, it should firstly provide evidence that it has reflected on the failings identified in this report and reviewed its processes regarding pressure sore management accordingly and secondly, provide evidence that nursing staff have reflected upon the importance of informing patient’s families of any ward changes and that this is reflected in patient’s nursing records.