Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment outside hospital

Case Reference Number



Not Upheld

Mrs H complained about the care provided to her late mother, Mrs B, by her GP Practice, which is directly managed by Betsi Cadwaladr University Health Board. Mrs H was concerned that between September 2019 and February 2020 the Practice missed opportunities to make an appropriate and timely referral to secondary care that may have allowed the earlier identification and treatment of the internal bleeding that caused Mrs B’s death.

The Ombudsman did not uphold the complaint. He found that there were no clinical signs which could have alerted clinicians at the Practice that Mrs B was experiencing internal bleeding, or was likely to do so. The actions taken by the GP who saw Mrs B were clinically appropriate based on the evidence available to her at the time.

The Ombudsman did, however, identify some learning points relating to the prescription of prednisolone and whether further consideration could have been given by the GP to Mrs B’s symptoms of breathlessness and test results which indicated high levels of inflammation, albeit he was satisfied that neither of these issues would have affected the course of events. He suggested that the Health Board should ask the GP to reflect on these concerns and discuss the contents of his report at her next annual appraisal and that the Health Board should convene a Significant Event Analysis meeting at the Practice to discuss the report.