Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr R complained about the treatment provided to his late brother, Mr Y, by the Health Board. He complained that the treatment his brother received for pulmonary fibrosis was inappropriate. Specifically he felt that as an Independent Expert considered there was sufficient indications that his brother had a particular type of pulmonary fibrosis (“UIP”), he would have benefitted from antifibrotic treatment for this. He also felt that his complaint about his brother’s care was not investigated and managed in accordance with the Putting Things Right Guidance (“the PTR Guidance”) and National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 (“the Regulations”), including that he was not treated fairly throughout this process, specifically in relation to the appointment of the Independent Expert, and the actions taken after this.

The investigation found that there was insufficient evidence to support the Independent Expert’s view that, during the period in question, Mr Y had UIP, and, furthermore, even if he had been eligible to receive antifibrotic treatment, due to the nature of his illness and other health issues, it would not necessarily have been appropriate for him. This complaint was therefore not upheld. However the investigation found that elements of the complaint handling in relation to the Independent Expert’s advice (including subsequently requesting further advice from an alternative specialist and appearing to prefer this, delaying informing Mr R of this, or of his entitlement to legal representation, and the resulting delay in providing Mr R with a final complaint response) were not in line with the expectations outlined in the PTR Guidance. This was an injustice to Mr R and this complaint was therefore upheld.

The Ombudsman recommended that the Health Board should apologise to Mr R for the issues identified, and offer him a payment of £750 for the errors identified with the complaint handling. She also recommended that it should amend its procedures to ensure that complainants are made aware of their rights to free legal representation at the start of any joint instruction process, in line with the Regulations, and also that when the Health Board agrees joint instruction of an independent adviser with a complainant, if it disagrees with that subsequent advice, any further action it takes to secure further advice must be agreed with the complainant.