Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

Mr X was 70 years old with a history of type 1 diabetes and he had dialysis at home 6 days weekly. He had other comorbidities (heart disease) and had a below the left knee amputation. On 2 December 2020 Mr X attended Ysbyty Glan Clwyd (the Hospital) with gangrenous right toes. He was admitted on 3 December. On 15 December Mr X had a below the right knee amputation. On 26 December Mr X’s stump had wound edge necrosis (where body tissue dies due to lack of blood supply) and 2 days later he had an above the right knee amputation. Mr X had dialysis 3 times weekly at the Hospital between 7 and 30 December. On 2 January 2021 Mr X was due to have dialysis, but he suffered a cardiac arrest and sadly, died. Mrs X complained that Mr X’s food was not properly monitored that led to a high potassium level on 14 December. She said that Mr X was not weighed before dialysis on 26, 28 and 30 December. Mrs X said that on 1 January 2021 Mr X did not have dialysis as he should have.

The Ombudsman found that Mr X’s regular blood tests showed the potassium levels were at expected levels. Mr X was aware of his potassium levels and to avoid such foods. Three times weekly dialysis kept Mr X’s potassium at acceptable levels apart from 14 December. However, on this day he had high blood sugar, acidosis at elevated levels. The 4-hour dialysis was appropriate and the blood sugar was controlled with insulin. This aspect of the complaint was not upheld.

The Ombudsman had no criticism that Mr X was not weighed on 26, 28 and 30 December as it was potentially risky to weigh patients in bed after amputation. This aspect of the complaint was not upheld. She also found that as Mr X had dialysis on 26,28 and 30 December, the next date for dialysis would have been on 2 January 2022. This aspect of the complaint was also not upheld.