Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained about her late mother’s (“Mrs B”) nursing management and care particularly while an inpatient at Llandudno General Hospital (“the Second Hospital”) from April 2020. She also had concerns about the management and monitoring of her mother’s urinary tract infection (“UTI”), urinary output and low sodium level due to syndrome of inappropriate antidiuretic hormone secretion (“SIADH” – a condition where the body produces an excess of a water-retaining hormone, causing hallucinations, disorientation, nausea and a coma in severe cases).

Other areas of concern that Mrs A raised related to her mother’s initial discharge process, poor communication and the Health Board’s complaint handling and complaint response.

The Ombudsman’s investigation found evidence of administrative and clinical failings, some of which related to basic nursing care at the Second Hospital. These ranged from incomplete, inadequate nursing documentation, to timely re-assessments not being carried out, for example around Mrs B’s nutritional requirements. These were to varying degrees also a feature when it came to the presence and management of her post-operative staples – which were not documented or commented upon at a nursing or indeed medical level – Mrs B’s catheter usage, UTI management and the initial discharge process. Additionally, the investigation, whilst acknowledging the considerable challenge for staff that the COVID-19 pandemic posed, found ineffective communication was a contributory factor in the failings in Mrs B’s care as well as contact with the family. From a medical perspective, it was identified that there was a lack of appropriate care and attention when it came to Mrs B’s SIADH management which led to missed opportunities to stop Mrs B’s low sodium level worsening. The Ombudsman identified that to the extent set out in the report, Mrs A and her mother had been caused an injustice and in relation to Mrs B’s SIADH the delay in her rehabilitation and recovery could have been lessened. Given the service failings and in some instances, maladministration found, these parts of Mrs A’s complaints were upheld.

From a complaint handling perspective, the Ombudsman’s investigation noted that the Health Board had apologised in its complaint response for the “significant delay” in responding to Mrs A’s complaint. The Ombudsman identified missed opportunities to have learnt lessons from Mrs A’s complaint – as not all the failings (for example around the SIADH monitoring) that the Ombudsman identified were recognised by the Health Board. The injustice for Mrs A was that she had to complain further in order to obtain answers. Given the evidence of maladministration, this aspect of Mrs A’s complaint was also upheld.

The Ombudsman made a range of recommendations to address the clinical failings identified. These included the Health Board making an apology to Mrs A, reflective learning by clinicians regarding their clinical practice and training, as well as requiring improvement in clinical processes and documentation.