Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

Mrs A underwent a colonoscopy on 12 March 2020 at Ysbyty Gwynedd. She complained that a perforation in her bowel was not identified before she was discharged. Mrs A said that during the procedure her reports of discomfort were not acknowledged and that she was not adequately monitored during recovery. Mrs A said that subsequently there was a failure to have immediately repaired the perforation. Mrs A said that poor and inadequate record keeping affected her care. Finally, she complained about the Health Board’s complaint handling and the robustness of its response.

The Ombudsman’s investigation concluded that, in the absence of the clinical indicators that would have raised the suspicion that Mrs A had suffered a perforation, staff were unable to alert her of this. The Ombudsman was also satisfied that Mrs A was appropriately monitored prior to her discharge. The Ombudsman was also satisfied that it was entirely reasonable to have waited to see whether the perforation healed itself prior to surgery, as can happen in such cases. The Ombudsman was satisfied that Mrs A’s clinical records reflected the clinical findings and care provided to her and were reasonable and adequate. The Ombudsman was also satisfied that the complaint response was robust and timely and this aspect of Mrs A complaint was not upheld.