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 on behalf of her late husband, Mr A, about his treatment and care when he was admitted to hospital with shortness of breath. Mrs A said that the Health Board failed to seek informed consent before a do not attempt cardiopulmonary resuscitation form (“the DNACPR Form” – the record of a decision by medical staff not to attempt to resuscitate a patient if their heart or breathing should stop) was put in place, provide appropriate levels of supplemental oxygen, certify the correct cause of death, and return Mr A’s belongings to his family.
The Ombudsman found that, although the DNACPR decision was clinically appropriate, contrary evidence and poor record keeping around the decision meant it was not possible to say whether Mr A and his family participated in the decision-making process in accordance with relevant guidance. There were no nursing entries or evidence of any monitoring of Mr A’s vital signs to assure Mrs A that he was receiving appropriate levels of supplemental oxygen. In view of his clinical presentation, the Health Board acted appropriately when certifying the cause of Mr A’s death as COVID-19. However, it failed to return Mr A’s property to his family in accordance with its policy, and to document that Mr A’s belongings had been disposed of, causing poor communication for a prolonged period after his death. The failings identified caused the family unnecessary uncertainty about the appropriateness of Mr A’s care and additional distress. Accordingly, aspects of the complaint were upheld.
The Ombudsman recommended that the Health Board should apologise to Mrs A and pay her financial redress of £750 in recognition of the impact of the failings on her. The Health Board should also share the findings of the investigation with relevant staff to ensure learning from the complaint.