Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms A complained about the care and treatment provided to her late partner, Mr B. Ms A complained that Betsi Cadwaladr University Health Board failed to assess and diagnose Mr B’s condition correctly when he attended the Emergency Department at Wrexham Maelor Hospital on 24 February 2020. Ms A also complained that Mr B was not advised to return to the Emergency Department if his condition worsened.

The Ombudsman found that Mr B was not appropriately assessed or diagnosed when he attended the Emergency Department. Mr B was prematurely discharged home without the appropriate tests being completed. Although these failings would not have altered the clinical outcome for Mr B it was determined this was an injustice to him and Ms A, who subsequently had to attempt to resuscitate him at home. It was not possible to determine what advice had been provided to Ms A and Mr B when he was discharged from the Emergency Department. As a result, the Ombudsman was not able to reach a finding on that part of the complaint.

The Health Board agreed to apologise to Ms A for the failings identified and make a payment to her of £1500. It also agreed to share the investigation report with relevant staff and review its procedures for assessing chest pain in the Emergency Department to address the failings identified.