Report Date


Case Against

A GP Practice in the area of Betsi Cadwaladr University Health Board


Clinical treatment outside hospital; GP

Case Reference Number



Upheld in whole or in part

Mrs A complained that the GP Practice’s management and care of her late father Mr B’s deteriorating kidney function in 2022 was not to an appropriate standard.

The Ombudsman’s investigation found that most of the appointments and interactions relating to Mr B’s care, together with the medication management of his oedema, in the face of deteriorating kidney function, were reasonable and appropriate.

However, there were instances identified when clinical decision-making ran counter to clinical and prescribing guidance, or expert advice received was not followed. This raised questions and concerns about the effectiveness of clinical oversight and monitoring at times in Mr B’s case. This was especially so given the absence of robust documentation to support some of the clinical decision-making. The investigation identified that where there are different clinicians involved in a patient’s care, a shared plan is important. Had such a plan been in place, it would have provided more clarity concerning Mr B’s management given his deteriorating kidney function.

The investigation found that the injustice for Mrs A and her father was that the failings identified creates some uncertainty about the effectiveness of Mr B’s care and management, given his deteriorating renal function. To that extent service failings were found. Additionally, administrative failings around documentation were found to amount to maladministration. Mrs A’s complaint was upheld.

The GP Practice agreed to implement the Ombudsman’s recommendations and apologise to Mrs A. It also agreed to carry out learning around prescribing to older people; undertake additional reflection in order to learn lessons and introduce process changes to improve clinical decision-making.