Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr B complained about the care and treatment provided by Betsi Cadwaladr University Health Board (“the Health Board”) to his wife, Mrs B.

Complaint 1

Mr B complained that the operation to remove Mrs B’s appendix was unduly delayed. The Ombudsman’s investigation found that after appendicitis was suspected in August 2019, there was no undue delay in arranging appropriate investigations or treatment, including the operation to remove Mrs B’s appendix. The Ombudsman did not uphold this complaint.

Complaint 2

Mr B complained that there was a failure to investigate the cause of Mrs B’s breathing difficulties in a timely manner. The investigation found that there was a failure to provide Mrs B with the expected level of care after the surgery to remove her appendix. There was a failure to identify the underlying cause of her breathing difficulties and to provide appropriate and timely treatment. There was also a failure to recognise signs that her condition was deteriorating and take appropriate action. The Ombudsman found, on a balance of probabilities, that Mrs B’s cardiac arrest and lengthy admission to the intensive care unit would likely have been avoided if she had received appropriate care.

The Ombudsman was concerned that these events had taken a considerable toll on Mrs B’s physical and mental wellbeing, which was a very serious injustice to her. Mrs B had been left with health and mobility problems that she would not have expected to have to cope with in her 50s and which may significantly limit her quality of life for years to come. Mr B had also suffered significant injustice through the distress he

experienced during his wife’s admission and afterwards in adapting to the need to provide ongoing physical and psychological support to her. The Ombudsman upheld this complaint.

Extended investigation

During the investigation, a concern arose that the Health Board had failed to arrange appropriate follow-up and treatment for Mrs B in response to a scan in September 2017. The Ombudsman used the recently introduced “own initiative” power to extend the investigation to look at the concern, which Mr and Mrs B had been entirely unaware of. The investigation found that, in response to the scan result, the Health Board should have arranged to remove Mrs B’s appendix but failed to do so. As a result, there was a missed opportunity to avoid the deterioration in Mrs B’s health which occurred after she developed appendicitis in 2019. The Ombudsman upheld this complaint.

The Ombudsman noted that had her office not started an “own initiative” investigation, this significant failing leading to serious injustice to Mr and Mrs B would not have come to light. This demonstrated why the “own initiative” power is needed, in the public interest, and for individuals who come to the Ombudsman.

The Ombudsman’s Recommendations

The Ombudsman recommended that within 1 month, the Health Board should:

a) Apologise to Mr and Mrs B for the failings and associated injustices identified in the report.

b) Make a payment to Mr and Mrs B of £10,000, reflecting the serious injustices arising from the missed CT colonography finding in 2017 and the poor post-operative care in 2019.

c) Share the report with the First and Second Consultants for the purposes of reflection and discussion at their next annual appraisals.

The Ombudsman also recommended that within 2 months of the report, the Health Board should provide evidence that the report has been discussed at a surgical clinical governance meeting and appropriate learning points shared with relevant clinical teams.