Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Miss K complained about the care and treatment her mother, Mrs L, received following her admission to Ysbyty Glan Clwyd on 18 June 2020. In particular, Miss K was unhappy about the failure to diagnose Mrs L with cirrhosis of the liver, the failure to treat appropriately and determine whether Mrs L acquired pneumonia during her admission at the Hospital, the failure to inform Mrs L’s family that she had contracted sepsis and the poor nursing care Mrs L received while on Ward X, including food and fluid intake and pain relief.

The Ombudsman’s investigation found that Mrs L’s admission had nothing to do with her liver and that the tests she underwent during her admission, including a CT scan, did not indicate that she had cirrhosis of the liver, and Mrs L’s pneumonia, whilst hospital acquired, was treated appropriately with antibiotics. These elements of the complaint were not upheld.

Mrs L’s pain relief, food and fluid intake were dealt with appropriately; however, the Ombudsman found that her medical documentation was not always completed correctly in accordance with appropriate guidance. Whilst this was a service failure, it did not cause Mrs L any injustice and so this element of the complaint was not upheld.

Finally, the Ombudsman found that Mrs L’s sepsis diagnosis was not communicated to her family, including Miss K, and so they were unaware of what actions were being taken as Mrs L became more frail and less responsive. The Ombudsman upheld this part of the complaint.

The Ombudsman recommended that the Health Board apologise to Miss K for this service failure and the Health Board agreed.