Source · PSOW (Public Services Ombudsman for Wales)

Betsi Cadwaladr University Health Board

PSOW (Public Services Ombudsman for Wales) Upheld Reference PSOW-202101775 Sector Health Category Clinical treatment in hospital Decided 25 March 2022

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Full decision

Ms A complained about the care she received at Ysbyty Glan Clwyd. The investigation considered whether Ms A was a patient during her stay on the Day of Surgery Arrival ward (“DOSA ward”) between 22 and 23 September 2020 and whether it was clinically appropriate that no observations were undertaken during this stay. In addition, Ms A also complained that her complaint was not investigated adequately by the Health Board.

The investigation found that Ms A’s discharge had not been fully completed, she remained within the hospital on award and so she was still under the care of the Health Board. The misconception that Ms A was not a patient, impacted upon the level of care she was provided; Ms A’s observations should have been taken. The failure to do so led to Ms A feeling a range of adverse emotions and left her unable to determine whether her blood pressure was within a range that required her to self-administer her prescribed medication. It also found that the Health Board did not investigate Ms A’s concern properly and appropriately.

The Health Board agreed to apologise to Ms A and pay her financial redress of £250 in recognition of the failures in complaint handling. In addition, it agreed to requests that the nursing staff involved prepare written reflections on Ms A’s experience and have an opportunity to discuss these with their line manager. Furthermore, it agreed to arrange for a Staff Nurse and Health Care Support Worker on the DOS Award to attend specific customer care training and revisit the Equality and Diversity mandatory training. Finally, it agreed to reviews its Discharge Policy and develop a Discharge/Transfer Lounge Protocol.

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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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