Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

Miss N complained about the care and treatment her mother, Mrs P, received prior to, and during, her 4 days of respite care (funded by Betsi Cadwaladr University Health Board (“the Health Board”)) at a nursing home (“the Nursing Home”). Miss N said that the seriousness of her mother’s condition was missed and this resulted in a perforated bowel and her subsequent death.

The Ombudsman found that the District Nursing service (“the DN service”) that visited Mrs P on a monthly/6 weekly basis, did not record every home visit or care assessment (contrary to published guidance) nor did it provide the Nursing Home with a more up-to-date nursing assessment prior to Mrs P’s respite. These were service failures as there is uncertainty as to whether changes in her bowel functions might have been recognised sooner. The Ombudsman also concluded that the Nursing Home should have sought an emergency visit from a local GP service as concerns about Mrs P’s bowel functions were noted soon after she arrived. The Ombudsman could not be certain that this action would have changed the outcome, however, the uncertainty was an injustice to Mrs P and Miss N. The Ombudsman upheld Miss N’s complaint.

The Ombudsman recommended that the Health Board apologise to Miss N and make a redress payment of£750 to reflect his findings. He also recommended that the Health Board share his findings with relevant staff, including the Nursing Home, and for the DN service to review its current approach to care/care planning/bladder and bowel assessments and how it shares this information with home carers to ensure a co-ordinated approach. The Health Board agreed to implement the recommendations.