Report Date

21/11/2024

Case Against

Betsi Cadwaladr University Health Board

Subject

Medical records/standards of record-keeping

Case Reference Number

202404887

Outcome

Early resolution

Mrs A complained that Betsi Cadwaladr University Health Board (“the Health Board”) failed to update her or respond to her second complaint about her late daughter’s care and treatment. She said that 16 months after she submitted the complaint, the Health Board said that it was unable to respond to her concerns because her daughter’s medical records were missing.
The Ombudsman decided that the missing medical records resulted in the loss of opportunity for Mrs A to have an independent investigation into her daughter’s care and treatment. She said that this caused a lasting injustice to Mrs A. The Ombudsman also decided that the Health Board’s complaint handling caused delays and frustration for Mrs A. She decided to settle the complaint without an investigation.
The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs A for the missing records and offer a redress payment of £1,250 for the loss of opportunity to have her complaint considered. The Health Board agreed to clarify when it discovered the records were missing, take appropriate action to reduce the risk of future loss, and to continue to search for the records. It also agreed to apologise to Mrs A for the issues identified with the complaints handling and offer her £250 redress for the time and trouble taken. Finally, it agreed to respond to aspects of the complaint that were not reliant on the missing records and complete all the agreed action within 6 weeks.