Report Date


Case Against

Betsi Cadwaladr University Health Board


Prisoner Care

Case Reference Number



Upheld in whole or in part

Mr J complained about the lack of care and treatment provided by Betsi Cadwaladr University Health Board (“the Health Board”) from May 2021 in response to concerns he raised about experiencing chest pain, blood in his stools and knee pain.

The Ombudsman’s investigation concluded that Mr J’s presenting symptoms, which were triaged by a nurse, should have been discussed further with a GP so a decision could be made as to whether Mr J required further tests. This did not happen and was a service failure. It was also of concern that Mr J’s stool sample was not sent for analysis, as this could have led, potentially, to an indication of the issues Mr J was experiencing. In addition, Mr J should have been assessed more promptly when he requested to see a GP on 27 July about stress, anxiety and depression. He was not seen for a further month; this was also a service failure. Both these service failures led to a delay in Mr J’s symptoms being investigated further. This was an injustice to Mr J and the complaint was upheld.

The Ombudsman recommended that the Health Board should apologise to Mr J and arrange appropriate treatment should he still be experiencing the same symptoms. It was also recommended that the staff involved in Mr J’s care should reflect on the findings of the Ombudsman’s report and consider what lessons could be learnt, with particular emphasis on escalating serious concerns more quickly. The Health Board agreed to the recommendations.