Source · PSOW (Public Services Ombudsman for Wales)

Betsi Cadwaladr University Health Board

PSOW (Public Services Ombudsman for Wales) Upheld Reference PSOW-201905922 Sector Health Category Clinical treatment in hospital Decided 15 July 2021

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Mrs A complained that the Consultant Gastroenterologist (“the Gastroenterologist”) failed to diagnose her gallstones in 2017 and dismissed her subsequent diagnosis of Laryngopharyngeal Reflux (“LPR” – the backflow of the stomach contents up into the food pipe and all the way to the throat and/or the voice box). She also complained that she received poor care at the Rapid Access Clinic (“RAU”) at Glan Clwyd Hospital (“the Hospital”) on 26 April 2019. Finally, Mrs A complained that the Health Board’s handling of her complaint was inadequate.

The Ombudsman’s investigation found that Mrs A’s clinical symptoms were not indicative of gallstones when she was admitted to the Hospital in 2017. The investigation found some communication failings by the Gastroenterologist when it came to Mrs A’s subsequent diagnosis of LPR, but noted that the misunderstanding arose because of Mrs A seeking both NHS and private care. This aspect of Mrs A’s complaint was upheld. In relation to the care in the RAU the Ombudsman was satisfied that the Consultant reviewing Mrs A provided reasonable and appropriate care to rule out a pulmonary embolism. This aspect of Mrs A’s complaint was not upheld.

In terms of complaint handling the Ombudsman found there was excessive delay in responding to Mrs A’s complaint and that the failure by the Health Board to identify areas where lessons could be learnt affected the robustness of its complaint response. As a result of these failings it led to Mrs A engaging in protracted correspondence causing her an injustice. The Health Board agreed to implement the Ombudsman’s recommendations which included a written apology and time and trouble payment of £250 to Mrs A as well as improving the processes for the investigation and treatment of LPR and closer multi-disciplinary working between the Ear, Nose and Throat and Gastroenterology teams.

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