Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Early resolution

Ms P complained about care provided to her mother, Mrs Q, by the Health Board during her admission to the Emergency Department (“the ED”) at Ysbyty Glan Clwyd from November 30 2021. In particular, she complained that the Health Board failed to assess and transfer her mother to a ward in a timely manner and that, after waiting for more than 28 hours in the ED, she fell and broke her hip and wrist. Ms P complained that the Health Board had failed to put in place adequate falls prevention measures prior to this and that her mother’s general health condition had deteriorated drastically as a result of the fall.
Having considered the available evidence, the Ombudsman was concerned that the Health Board’s response to Ms P’s complaint was incomplete. In particular, the response did not include adequate consideration of whether the falls risk management was adequate.
In response to the Ombudsman’s concerns the Health Board agreed to re-consider and re-issue its complaint response within 3 months to include a full account of whether the management of Mrs Q’s falls risk was appropriate. The Health Board also agreed to include a full explanation of its updated decision regarding qualifying liability and detailed updates on progress in relation to the action plan included in its initial complaint response.