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 her brother’s (“Mr B”) care and management while an inpatient at Glan Clwyd Hospital (“the Hospital”) between 10 and 29 October 2020. She said that staff failed to communicate with her, her brother, and the family about her brother’s deteriorating condition. Finally, Mrs A complained about the adequacy and the robustness of the Health Board’s complaint response.
The Ombudsman’s investigation found that broadly the care Mr B received was reasonable, however there were instances where the care could have been better given the severity of Mr B’s condition. For example lack of daily medical review and senior clinical and cardiology input was unsatisfactory. The investigation also highlighted areas of nursing care which fell below expected standards, including the failure to monitor Mr B’s cannula, which meant that Mr B developed an avoidable infection, suffered pain, and needed treatment with antibiotics. The investigation found that the shortcomings in the nursing care were compounded by poor communication and inadequate record keeping, such as the failure to record fluid intake and output, which meant that it was difficult to know if Mr B received a reasonable standard of nursing care on a daily basis. These aspects of Mrs A’s complaint were upheld. The Ombudsman also upheld Mrs A’s complaint about poor complaint handling.
The recommendations made included the Health Board apologising to Mrs A and her family for the shortcomings identified in this report, as well as providing training and support to nursing staff on the Ward on the expected standards in maintaining nursing related documentation, patient risk assessment documentation, care planning and care bundles and communication.