Mrs Y complained that her husband, Mr Y, was referred to an NHS Trust outside of Wales (“the English Trust”) in 2017 by Betsi Cadwaladr University Health Board for surgery which had not taken place. The investigation considered whether Mr Y’s surgery was unreasonably delayed and whether the Health Board had appropriately responded to Mrs Y’s complaint.
The investigation found that the decision that Mr Y was not fit for surgery in 2019 was clinically reasonable. However, Mr Y was also referred for endoscopic procedures (using a tube and camera) during the complaint period. The investigation found that a procedure attempted on 4 May 2021 was cancelled as it needed to be undertaken in theatre, rather than the endoscopy unit. This was known prior to the procedure so was an unnecessary error. There was an unreasonable delay in performing a procedure in October 2022. It was also found that this procedure had unsuccessfully been attempted 3 times previously so it was questioned why it had been attempted again when Mr Y’s clinical presentation had not changed. Mr Y’s clinical care was complex, and many aspects of it were to a reasonable standard, but the complaint was upheld because of the failings the investigation identified.
The investigation also found that the Health Board was correct to advise Mrs Y to complain to the English Trust about the concerns she had about Mr Y’s clinical treatment. However, the Health Board maintained overall responsibility for ensuring Mr Y’s treatment took place within an appropriate Page 2 of 2 timeframe. The Health Board made no attempt to satisfy itself that this was the case. There was also insufficient information shared between the Health Board and the English Trust. This aspect of the complaint was upheld. The Ombudsman noted that she has raised concerns about commissioning arrangements with the Health Board previously.
The Health Board agreed to apologise to Mrs Y for the failings identified and offer a financial redress payment of £500 for the distress and uncertainty caused. It also agreed to review its responses to the complaints made to identify lessons to be learnt, particularly in relation to its responsibilities for patients whose care has been commissioned outside of Wales. Finally, it agreed to write to the English Trust as part of its commissioning arrangements to bring to its attention the concerns identified.