Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs X complained about the care provided to her later mother, Mrs Y, by the Health Board and the GP Practice following a fall, on 2 November 2018, at the care home where Mrs Y lived. The investigation considered whether the Trainee Advanced Nurse Practitioner (“TANP”) failed to appropriately examine Mrs Y on 5 November and therefore failed to identify that she had suffered a serious injury (diagnosed in hospital 4 days later as a left knee fracture). It also considered whether a GP at the GP Practice failed to send Mrs Y for an X-ray on the same date following a discussion with the TANP, and failed to visit Mrs Y to examine her.

The Ombudsman found that the TANP failed to carry out an appropriate examination of Mrs Y and failed to keep appropriate records in relation to the examination and follow up with the GP. This complaint was upheld.

The Ombudsman found that the GP’s approach to Mrs Y’s clinical situation was appropriate and that the decision not to send Mrs Y for an X-ray and to wait and see how she responded to an increase in pain relief was reasonable. In addition, as the TANP had examined Mrs Y and reported her findings to the GP, it was acceptable practice for the GP not to arrange a visit to examine Mrs Y. This complaint was not upheld.

The Health Board accepted the Ombudsman’s recommendations to apologise to Mrs X for the identified failings and to remind the TANP of record keeping requirements in line with the standards of relevant clinical/nursing guidance.