Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

Miss X complained about the treatment and care provided to her late mother, Mrs Y, by the Health Board in February 2021. In particular, she was concerned that treatment for a fistula was delayed and that she had disagreed with the DNACPR decision.

The complaint was not upheld.

The Ombudsman found that, although the initial management plan for the fistula could have been clearer, there was no undue delay in pursuing investigations or determining treatment. A discussion with Mrs Y at the outset about the fistula and treatment options might have been helpful for her and provided reassurance. However, this would not have affected the overall management or the outcome.

The DNACPR decision was reasonable, a discussion with Mrs Y had taken place and the correct form had been completed. The DNACPR decision did not have any effect on the treatment provided. However, there were shortcomings identified relating to the recording of the decision.