Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms A complained that Betsi Cadwaladr University Health Board failed to identify the complex nature of her labour promptly, manage that labour properly and provide appropriate postnatal care for her. She said that the Health Board had not, after 3 days of hospital visits and telephone calls from her, questioned her complicated labour. She suggested that it had delayed her Caesarean-section unnecessarily and that she had developed complications because of the way in which it managed her labour. She reported that the care that she had received after her discharge from hospital was “almost non-existent”. She also raised concerns about her 8-week postnatal check and having to return to hospital for intravenous antibiotics.

The Ombudsman, whilst recognising that Ms A’s labour was very difficult for her, did not determine that it was complex. She did not therefore find that the Health Board failed to identify the complex nature of Ms A’s labour promptly. She did not uphold this aspect of Ms A’s complaint. She found that the Health Board did not fully acknowledge the prolonged nature of Ms A’s painful contractions during the very early phase of her labour and that that omission added to Ms A’s distress. She was satisfied that the Health Board’s management of Ms A’s labour was, with the exception of the acknowledgement issue identified, clinically appropriate. She upheld that part of Ms A’s complaint, which concerned the management of her labour, to a very limited extent. She found that the postnatal care provided for Ms A was appropriate. She did not uphold this element of Ms A’s complaint.

The Ombudsman recommended that the Health Board should write to Ms A to apologise for the acknowledgement failing identified and to explain why there was a delay in inducing (starting artificially) her labour. She asked it to share her investigation report with relevant midwifery staff. She recommended that it should take specific action to improve the recording, by Midwives, of the number of telephone calls made by expectant mothers during the very early phase of their labour. The Health Board agreed to implement these recommendations.