Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

Mrs Q complained that Betsi Cadwaladr University Health Board (“the Health Board”) failed to act on her concerns about her mother, Mrs R’s, oedematous legs for 10 days. Mrs Q said this lack of prompt and effective treatment led her mother to develop a bacterial infection (necrotising fasciitis) which was a contributing factor in her death on 27 May 2021.

The Ombudsman’s investigation found that despite Mrs R being unwell, she displayed no clinical signs of infection. Mrs R was visited during this time by District Nursing staff and her GP, and the Ombudsman was satisfied, overall, with the care she received. The Ombudsman concluded that her sudden deterioration could not have been anticipated. The complaint was not upheld.

However, the Ombudsman did have concerns about the record keeping of the District Nursing service. He invited the Health Board to share the report with its District Nursing staff and for it to feedback on any improvements it would make.