Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A’s complaint related to the care and treatment that her late husband, Mr A, received during his admissions to Wrexham Maelor Hospital (“the First Hospital”) and Mold Community Hospital (“the Second Hospital”) in mid-2019. Specifically, Mrs A complained that her husband was inappropriately discharged from the First Hospital on 18 June 2019with no Social Worker or outpatient follow-up in place. Following his re-admission the next day, Mrs A complained that there was a delay in completing referral paperwork (including Social Services and Occupational Therapy) for a care package to be arranged, which meant that her husband had to be transferred to the Second Hospital rather than discharged home. Mrs A also raised concerns that the Health Board later failed to promptly identify and respond to her husband’s deterioration during his stay in the Second Hospital. Finally, Mrs A complained that the Health Board inappropriately took what she considered to be a private conversation with a hospice nurse forward as a complaint, and so discussed and shared her personal information within the Health Board without her permission or any consent having been given.

The Ombudsman found that although there was a lack of clarity around certain aspects of the discharge plan, such as in relation to a social work assessment, this had no bearing on Mr A’s re-admission to the First Hospital. On balance, the Ombudsman found that it was reasonable from a medical perspective to discharge Mr A on 18 June. The Ombudsman also could not conclude that Mr A’s later transfer to the Second Hospital would have necessarily been avoided had the accepted delay in sending a referral to Social Services not occurred. As a result, the Ombudsman did not uphold these aspects of the complaint. However, the Ombudsman found that Mr A’s deterioration while he was in the Second Hospital was not appropriately monitored or acted on, and that there was a lost opportunity to have a full and clear discussion with Mrs A about possible options moving forward. With regard to complaint handling, the Ombudsman concluded that the initial confusion and mismanagement of Mrs A’s informal concerns was then exacerbated by the wording of the letters she subsequently received. As a result, the Ombudsman upheld these aspects of Mrs A’s complaint.

The Ombudsman recommended that the Health Board apologised to Mrs A for the failings identified. The Ombudsman also recommended that the Health Board shared the final report with a doctor from the Second Hospital and confirmed that the report would form part of their next appraisal.