Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs S complained about the care and treatment her late husband, Mr S, received from July 2020 until his death 2 months later. In particular, Mrs S said the Health Board ignored her concerns about Mr S’s change in behaviour following palliative radiotherapy treatment, Mrs S’s requests for further input from the District Nursing service to attend to her husband’s face lesions were ignored, a DNACPR form was completed without discussion with Mrs S and her family and communication from a Consultant Haematologist with Mrs S and her family was poor.

The Ombudsman’s investigation found that Mr S’s overall deterioration was more likely to have been due to the progression of his Chronic Lymphocytic Leukaemia (a cancer that affects the white blood cells) rather than the palliative radiotherapy treatment. In relation to Mr S’s DNACPR form, appropriate discussions took place with Mr S beforehand, and he understood its implications. Discussions with his family took place shortly afterwards. These elements of Mrs S’s complaint were not upheld.

In addition, the Ombudsman’s investigation found that some DN Service medical notes were missing, so it was not possible to be certain whether a request for further input was ignored. With regard to the Consultant Haematologist’s communication with Mrs S and her family, the Ombudsman acknowledged that the Health Board had already addressed the matter and had apologised to Mrs S. The Ombudsman concluded that the Health Board’s actions were sufficient and took no further action.