Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr X was diagnosed with glioblastoma multiforme of the brain (an aggressive type of cancer) and it was determined that he was for palliative care at home. On 7 October 2019 he was referred by the Walton University Hospital (a specialist NHS referral centre outside Wales) and to his local District Nursing Service. On 1 November Mr X’s GP referred him to his local Palliative Care Team. On 29 November Mr X sadly died. Mr X’s daughter, Ms Y, complained about the palliative care and treatment her father received at home between 7 October and 29 November 2019.

The Ombudsman found that the care and treatment that Mr X received from the Palliative Care Team and District Nurses was of a reasonable standard. However, she found that District Nursing entries for 7 and 11 November were entered 4 months later. This cast doubt on their accuracy. On that basis the Ombudsman partly upheld the complaint.

The Health Board agreed to implement the Ombudsman’s recommendations and apologise to Mrs X and Ms Y for the failings, and that each member of the District Nursing Team be reminded of the Royal College of Nursing Record Keeping Guide about clear, contemporaneous record keeping.