Report Date


Case Against

Betsi Cadwaladr University Health Board


Independent Health Care providers

Case Reference Number



Upheld in whole or in part

Mr A, through his Community Health Council Advocate, complained about the care and treatment his father, Mr B, received at the Care Home. Mr B’s care needs meant he was in receipt of NHS Continuing Health Care (“NHSCHC”) from the Health Board who were responsible for monitoring the care provided to Mr B, as well as meeting relevant aspects of his care home fees. Mr A’s concerns included the management of his father’s skin integrity and the safeguarding action taken in relation to this. He also complained about a delay in providing his father with a pressure airflow bed, a specialised chair and hoist. He also questioned why the NHSCHC did not include the ongoing costs his father incurred for a room with a sea view, and hair and nail cutting services. Finally, he was unhappy with the Health Board’s complaint response.

The Ombudsman’s investigation concluded that Mr B’s pre-existing health conditions meant preventative strategies to address his pressure ulcers were difficult. That said, the investigation highlighted administrative shortcomings in relation to the Care Home documentation which in the absence of the records, meant the Ombudsman was unable to definitively say what prevention measures had been put in place by the Care Home to minimise the risk of Mr B developing skin damage. The Ombudsman found that the lack of documentation not only amounted to maladministration but caused service failings and therefore an injustice to Mr B.

The Ombudsman was concerned that the Health Board’s investigation failed to explore if Mr B’s pressure sores were preventable. This meant that an important part of its monitoring role, which requires it to have rigorous oversight and scrutiny of the commissioned body, was lost. The Ombudsman upheld these aspects of Mr A’s complaint.

The Ombudsman was satisfied that safeguarding concerns were dealt with in a timely manner by the Care Home and the Health Board, and the necessary specialist equipment provided. In addition, she concluded that NHSCHC had been correctly paid.

The Ombudsman recommended that the Care Home and the Health Board jointly apologise to Mr A for the shortcomings identified by the investigation. The Care Home was asked to provide evidence of what process it has put in place to prevent the loss of records happening again. The Health Board was asked to review its complaint handling on this case to identify areas where there were opportunities to learn lessons, Additionally, the Health Board should pay Mr A £250 for the shortcomings in complaint handling and review its complaint handling in this case.