Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr A complained about the care his late mother, Mrs B, received at Ysbyty Glan Clwyd in January 2020. In particular, he said that:
a) his mother’s lack of sedation resulted in her not sleeping and thus becoming confused
b) as a result his mother did not receive adequate hydration and nutrition
c) there were failings in communication, both between clinical teams and between staff and Mrs B’s family
d) doctors failed to consider putting in place a DNACPR (do not attempt cardiopulmonary resuscitation) order, meaning inappropriate resuscitation attempts were made.
In response to evidence gathered during this investigation, the Ombudsman used his “own initiative” investigation power under s4 of the Public Services Ombudsman (Wales) Act 2019 to extend the investigation to consider, as additional complaints:
e) whether the prescription of lorazepam (a medication used to treat anxiety and sleeping problems related to anxiety) and the dosage administered to Mrs B were appropriate
f) whether appropriate action was taken in response to Mrs B’s observations at 21.00 on 27 January.
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The Ombudsman did not uphold complaints a), b) and c). She upheld complaint d). The Ombudsman found that the clinician prescribing lorazepam for Mrs B had not seen her or satisfied themselves that they had all relevant information, and that Mrs B was given more than the recommended minimum dose. She also found that Mrs B was not monitored appropriately following this, and she was not reviewed by a doctor when her oxygen saturation was noted to have decreased. These were service failures, and the Ombudsman upheld complaints e) and f).
The Ombudsman recommended the Health Board apologise to Mr A for the failings she identified. She also made recommendations concerning consideration of DNACPR orders and monitoring of patients, as well as inviting the clinician involved to reflect on the wisdom of remote prescribing.
5 July 2022