Report Date


Case Against

Betsi Cadwaladr University Health Board



Case Reference Number



Upheld in whole or in part

Mrs A complained about the care and management her late husband, Dr A, received at Ysbyty Glan Clwyd (“the Hospital”) in April 2020. She said that medical and nursing staff failed to adequately communicate with her about her husband’s condition. Mrs A said that there were also inadequacies and inconsistencies in clinical record keeping. Finally, Mrs A complained about the Health Board’s complaint handling and the robustness of its complaint response.
The Ombudsman’s investigation concluded that although Dr A was not treated in accordance with national guidance on the treatment of strokes in adults, it would not have changed/altered Dr A’s eventual outcome and therefore he was not caused an injustice. In relation to the nursing aspects of Dr A’s care the Ombudsman’s investigation found instances where the care provided fell below a reasonable standard. This included missed opportunities to undertake timely nursing assessments/reassessments, and the provision of individualised care plans. The investigation also identified shortcomings in communication with Mrs A about her husband’s condition. These were compounded by instances of poor record keeping by the clinicians involved in Dr A’s care. The Ombudsman concluded that there were inadequacies in the Health Board’s complaint handling and that its complaint response was insufficiently robust when it came to identifying clinical and administrative failings and caused an injustice to Mrs A. The Ombudsman upheld Mrs A’s complaints.
The Ombudsman’s recommendations included apologising to Mrs A for the shortcomings identified by the Ombudsman’s investigation, providing additional training to nursing staff around documentation and care planning as well as addressing information and communication with families.