Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms A complained about the care she received at Ysbyty Glan Clwyd. The investigation considered whether Ms A was a patient during her stay on the Day of Surgery Arrival ward (“DOSA ward”) between 22 and 23 September 2020 and whether it was clinically appropriate that no observations were undertaken during this stay. In addition, Ms A also complained that her complaint was not investigated adequately by the Health Board.
The investigation found that Ms A’s discharge had not been fully completed, she remained within the hospital on award and so she was still under the care of the Health Board. The misconception that Ms A was not a patient, impacted upon the level of care she was provided; Ms A’s observations should have been taken. The failure to do so led to Ms A feeling a range of adverse emotions and left her unable to determine whether her blood pressure was within a range that required her to self-administer her prescribed medication. It also found that the Health Board did not investigate Ms A’s concern properly and appropriately.
The Health Board agreed to apologise to Ms A and pay her financial redress of £250 in recognition of the failures in complaint handling. In addition, it agreed to requests that the nursing staff involved prepare written reflections on Ms A’s experience and have an opportunity to discuss these with their line manager. Furthermore, it agreed to arrange for a Staff Nurse and Health Care Support Worker on the DOS Award to attend specific customer care training and revisit the Equality and Diversity mandatory training. Finally, it agreed to reviews its Discharge Policy and develop a Discharge/Transfer Lounge Protocol.