Source · PSOW (Public Services Ombudsman for Wales)

Betsi Cadwaladr University Health Board

PSOW (Public Services Ombudsman for Wales) Resolved / Early Resolution Reference PSOW-202601648 Sector Health Category Secondary care Decided 23 July 2026

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Original decision on the PSOW (Public Services Ombudsman for Wales) website ↗

Full decision

Mrs A complained that Betsi Cadwaladr University Health Board administered an overdose of morphine to her mother, resulting in her becoming unresponsive and needing 3 doses of reversal treatment.

The Ombudsman decided that the Health Board’s complaint response was unclear in respect of considering her mother’s age and weight when determining the dosage of morphine that she would need. The Ombudsman decided that a further complaint response was required to provide a better explanation. She decided to settle the complaint without an investigation.

The Ombudsman sought and gained the Health Board’s agreement to, within 1 month, apologise to Mrs A and to provide a further written explanation.

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