Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Miss X complained about the care and treatment that her late mother, Mrs Y received from the Health Board between 28 and 31 December 2019. The investigation considered whether the Health Board failed to act in a timely manner when Mrs Y suffered a seizure on 28 December and whether there was a delay in carrying out a medical review, providing medication and making a referral to Neurology.

The Ombudsman found that the decision to prescribe carbamazepine on 28 December to treat Mrs Y’s seizures was suboptimal. In addition, there was a delay in treating Mrs Y’s seizures which was likely due to a lack of planning, especially in a patient who was having active changes to their anti-epileptic medication. There was also a delay in making a Neurology referral especially in a patient who was known to Neurology, had a history of seizures and was at the time a patient on a ward where staff did not have seizure management expertise. These shortcomings amounted to a service failure which caused Mrs Y and Miss X an injustice. The Ombudsman upheld Miss X’s complaint.

The Health Board agreed to implement the Ombudsman’s recommendations to apologise to Miss X for the shortcomings identified and to share the report with the clinical team involved in Mrs Y’s care for reflection and learning.