Source · PSOW (Public Services Ombudsman for Wales)

Betsi Cadwaladr University Health Board

PSOW (Public Services Ombudsman for Wales) Upheld Reference PSOW-202101446 Sector Health Category Clinical treatment in hospital Decided 18 March 2022

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Mrs A complained about her brother’s (“Mr B”) care and management while an inpatient at Glan Clwyd Hospital (“the Hospital”) between 10 and 29 October 2020. She said that staff failed to communicate with her, her brother, and the family about her brother’s deteriorating condition. Finally, Mrs A complained about the adequacy and the robustness of the Health Board’s complaint response.

The Ombudsman’s investigation found that broadly the care Mr B received was reasonable, however there were instances where the care could have been better given the severity of Mr B’s condition. For example lack of daily medical review and senior clinical and cardiology input was unsatisfactory. The investigation also highlighted areas of nursing care which fell below expected standards, including the failure to monitor Mr B’s cannula, which meant that Mr B developed an avoidable infection, suffered pain, and needed treatment with antibiotics. The investigation found that the shortcomings in the nursing care were compounded by poor communication and inadequate record keeping, such as the failure to record fluid intake and output, which meant that it was difficult to know if Mr B received a reasonable standard of nursing care on a daily basis. These aspects of Mrs A’s complaint were upheld. The Ombudsman also upheld Mrs A’s complaint about poor complaint handling.

The recommendations made included the Health Board apologising to Mrs A and her family for the shortcomings identified in this report, as well as providing training and support to nursing staff on the Ward on the expected standards in maintaining nursing related documentation, patient risk assessment documentation, care planning and care bundles and communication.

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Other decisions involving Betsi Cadwaladr University Health Board

Reference Date Summary Outcome
PSOW-202601587 24 Jul 2026 Ms A complained that she was dissatisfied with Betsi Cadwaladr University Health Board’s response to her complaint about her inpatient … Resolved / Early Resolution
PSOW-202601648 23 Jul 2026 Mrs A complained that Betsi Cadwaladr University Health Board administered an overdose of morphine to her mother, resulting in her … Resolved / Early Resolution
PSOW-202504962 23 Jul 2026 Mrs A complained about the management and care provided to her late father, Mr B, at Betsi Cadwaladr University Health … Not Upheld
PSOW-202504789 30 Jun 2026 Mr B complained about the care and treatment received by his late wife, Mrs B, from the Health Board. The … Partly Upheld
PSOW-202601887 26 Jun 2026 Mr A complained that the Community Mental Health Team at Betsi Cadwaladr Health Board had failed to provide him with … Resolved / Early Resolution
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