Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr C complained about the care and treatment of his wife Mrs C, who sadly died on 16 October 2020. Mr C queried whether support of, and communication with, Mrs C and her family was appropriate during Mrs C’s inpatient stay. He also queried whether it was reasonable and appropriate for the Health Board to undertake an gastroscopy (“OGD”- Oesophago-Gastro Duodenoscopy) and whether it reached an appropriate standard. Finally, he asked whether care planning, including discussions around a Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) agreement for Mrs C, was reasonable and appropriate.

The investigation found that more could have been done to assist Mrs C to communicate with her family, to offer her the opportunity to receive support from her family during difficult conversations and to discuss her DNACPR wishes with her family. Also, incomplete documentation meant it was unclear why Mrs C’s deterioration occurred. These aspects of the complaint were therefore upheld. However, the investigation found it was reasonable for an OGD to be carried out and that this met an appropriate standard, this element was not upheld.

The Health Board agreed to the Ombudsman’s recommendations to apologise to Mr C and the family, to introduce a method of confirming that patients’ options to communicate with family and friends have been discussed and help offered, to remind treating clinicians that patients should be offered the opportunity to receive support from family or friends during difficult conversations and to add a prompt to the relevant form for clinicians to confirm they have checked for any earlier expression of wishes, when the patient has lost capacity. The Health Board also agreed to carry out an audit of a sample of records on the ITU ward to confirm if observations are being properly recorded.