Report Date


Case Against

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


Clinical treatment outside hospital; GP

Case Reference Number



Not Upheld

Mrs B complained about care and treatment provided to her late father, Mr D, by a GP Practice (“the Practice”) in the area of Betsi Cadwaladr University Health Board. The investigation considered whether the prescription in November 2021 of 2 mg of diazepam for Mr D was appropriate, especially given that the dosage was contrary to British National Formulary advice, that the medication increased the risk of respiratory depression and in light of his recent lower lobectomy (19 October 2021), which had resulted in a weakened respiratory system, and apparent breathlessness. It also considered whether the Practice failed to arrange a face-to-face appointment where appropriate examinations could have been carried out and whether the failure meant that an opportunity was missed by the Practice to have noticed the signs and symptoms of pneumonia which led to Mr D sadly dying 2 days after the telephone consultation.

The Ombudsman found that whilst the care and treatment provided by the Practice to Mr D on 18 November 2021 fell below a clinically acceptable standard, it did not cause an injustice to Mr D in terms of contributing to the nature or timing of his death. Mrs B’s complaint was not upheld.