Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Miss A complained on behalf of her father, Mr B, about the care and treatment provided to her mother, Mrs B, in March and April 2020. She complained specifically, that:
• A Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) decision was made on 25 March without properly consulting Mrs B or her family.
• The discharge from Ysbyty Gwynedd (“the First Hospital”) on 10 April was not appropriate.
• The transfer to the Ysbyty Penrhos Stanley (“the Second Hospital”) was not appropriate.
• The Health Board failed to inform the family in a timely manner that Mrs B’s condition was deteriorating following her admission to the Second Hospital.
The Ombudsman upheld the complaint about the DNACPR decision because, while the decision itself was clinically justified, the Health Board had failed to follow the proper process for documenting and discussing the decision with Mrs B and her family. The Ombudsman upheld the complaint that the discharge on 10 April was not appropriate, finding that the Health Board failed to take sufficient steps to ensure that Mrs B’s needs could be safely met at home. The Ombudsman also upheld the complaint about communication regarding Mrs B’s deterioration, to the limited extension that when contacting the family, the Health Board failed to take appropriate steps to arrange a visit before she died. The Ombudsman recognised factors relating to the COVID-19 pandemic which contributed to the failing, but considered that this was a serious injustice to the family. Finally, the Ombudsman was satisfied that the transfer to the Second Hospital was clinically appropriate. That part of the complaint was not upheld.

The Ombudsman recommended that the Health Board should apologise to Mr B and the family for the failings identified and should remind all medical staff at the First and Second Hospitals of the importance of following the appropriate DNACPR decision process.