Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs O complained about care provided to her father, Mr P, by Betsi Cadwaladr University Health Board. We investigated Mrs O’s concerns that:
• Following Mr P’s attendance at the Emergency Department on 9 August 2021, there was an undue delay in identifying his neck fracture and referring him for surgery

• The Health Board failed to provide appropriate care for Mr P’s post-surgical wound.
The investigation found that a failure to request follow-up scans led to a delay of more than 2 days in diagnosing Mr P’s spinal fracture. This meant he was put at avoidable risk of harm and missed out on protective measures which could have reduced his discomfort sooner. This complaint was upheld. The investigation also found that, when Mr P developed problems with his surgical wound, there was a failure to provide adequate continuity of care. This deprived him of the opportunity to receive care which potentially could have prevented the breakdown of his wound and may have spared him the need to visit multiple clinicians at different health settings over a short period of time. This complaint was also upheld.
The Ombudsman recommended that the Health Board apologise to Mr P for the failings identified and make a financial redress payment to him of £1000. The Ombudsman also recommended that the Health Board share learning points with relevant members of staff and meet with the NHS organisation which carried out the surgery on its behalf, to review arrangements for communicating and co-ordinating care. The Ombudsman was pleased that the Health Board agreed to implement these recommendations