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, Ms B’s care in hospital, when she was admitted after a fall. She queried whether sufficient preparation was made for Ms B’s first discharge from hospital, if insufficient information was provided to Ms B’s GP on her second discharge, and whether Ms B suffered any disadvantage as a result of this. She also complained about the lack of communication with the family in relation to establishing Ms B’s whereabouts when she was readmitted to hospital after her first discharge. Ms A also questioned if Ms B’s care in hospital was adequate, particularly given the later diagnosis that Ms B had probably suffered a stroke, including whether sufficient effort was made by the Health Board to establish Ms B’s level of understanding and independence before hospitalisation.

The investigation found that although Ms B was assessed as being suitable to be discharged as long as support (namely help from district nurses to assist with her insulin injections) was available, a transfer to a rehabilitation hospital may have been more suitable, and once it became apparent that support would not be available over the weekend, her discharge should have been delayed. It found that there was a significant delay in updating Ms B’s details on relevant record systems following her readmission, which meant that her family could not establish where she was when they contacted the hospital. The investigation also found that the discharge letter sent to Ms B’s GP did not provide sufficient detail about the findings and treatment within hospital. Finally, it found that while Ms B’s care, including communication with the family, was generally appropriate, there were additional tests and considerations which, if carried out earlier, could have revealed the likely reason for her initial fall. These complaints were therefore all upheld.

The Ombudsman recommend that the Health Board should remind staff of the importance of undertaking Multifactorial Fall Risk Assessments on older patients admitted after falls, and updating relevant records as soon as possible after a patient is admitted. It should also remind all staff involved in complaint handling to check that any timescales and actions have been updated since draft stage, when a final response is issued. In relation to the discharge issues the Ombudsman recommended that the Health Board should communicate with relevant partners (e.g. GPs/district nurses) regarding the importance of raising any failed discharge concerns, and also to consider the feasibility of appropriate ward staff being encouraged to also raise concerns after failed discharges as standard, to avoid cases like Ms B’s not being registered