Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

Mrs G complained that for 4 years, the Practice had prescribed the wrong steroid cream making her lichen sclerosis (“LS” – a chronic inflammatory skin disorder that affects the genital area) worse and causing her constant pain. Mrs G also complained that the Health Board’s complaint response repeated the Practice’s comments, and it did not carry out an investigation into her concerns.
The Ombudsman’s investigation found that the Practice had confused the names of steroid creams and Mrs G had been prescribed, at times, a different, less potent cream to that which had been prescribed by her Dermatologist. This was a service failure. However, the Ombudsman also concluded that guidance at the time suggested LS should not be treated in perpetuity with the strongest steroid cream and that at times using a less potent steroid cream was reasonable. Therefore, whilst the Ombudsman could not be precise about the significance of the injustice to Mrs G, the changes in steroid cream were not at the behest of the Dermatologist, and so it was difficult to evaluate accurately the effectiveness of the creams on Mrs G’s LS. The Ombudsman upheld this part of the complaint.

The Ombudsman was satisfied with the Health Board’s complaint response as the information contained with its letter, provided by the Practice, was correct at the time, and it had consulted its Head of Pharmacy before responding. It was not until the Ombudsman began their investigation that the Practice accepted that it had confused the steroid creams. The Ombudsman did not uphold this aspect of Mrs G’s complaint.

The Ombudsman recommended that the Practice apologise to Mrs G and provide assurances that it was taking steps to ensure errors like this do not happen again. The Practice agreed to the recommendations.