PSOW Individual Decisions

Miss A complained that Betsi Cadwaladr University Health Board had failed to arrange a meeting which she requested in September 2025. The Ombudsman found that the Health Board had failed to arrange a meeting with Miss X and her advocate. The Ombudsman said this caused frustration for Miss X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, offer an apology and explanation to Miss X for the delay in arranging a meeting and to arrange a meeting with Miss X and her advocate.

Mrs A complained about her brother, Mr B’s, care and management by the Health Board. We investigated her concerns about whether Mr B’s clinical management between January and June 2023 was appropriate. We also investigated whether the cancer diagnosis Mr B received in May 2024 could have been identified sooner. Finally, we investigated Mrs A’s concern that the Health Board’s complaint response was compromised by factual inaccuracies. The investigation found that, while Mr B was seen within an appropriate timescale following a dental referral in January 2023, the decision to remove him from the cancer pathway at his appointment in February 2023 was not appropriate. This led to a delay in carrying out a biopsy, reaching a diagnosis and commencing treatment for Mr B’s diagnosed cancer. This was a service failure. Even taking into account the delay in confirming Mr B’s oral cancer diagnosis, Mr B’s management and treatment would have been the same, even if the diagnosis had been reached sooner. This complaint was not upheld. The investigation found, in relation to the concern about whether Mr B’s cancer diagnosis in May 2024 could have been identified sooner, that the Health Board’s management of a non-specific lung nodule during a staging CT scan in May 2023 was appropriate and its management of Mr B at a maxillofacial appointment in February 2024 was appropriate, following a GP referral reporting a new lesion on the tip of Mr B’s tongue. The investigation found that while there were elements of the clinical management at a rheumatology appointment in April 2024, to investigate a cause for Mr B’s back pain, that were appropriate, there were a number of red flag indicators that, taken together should have prompted further assessment of Mr B’s symptoms. This was a service failure. Even taking this into account, an earlier identification of Mr B’s lung lesion and metastatic disease would not have altered the trajectory of Mr B’s cancer, management of if, or led to further

Mrs A complained about the care and treatment provided to her son by Betsi Cadwaladr University Health Board’s dermatology department. In particular, it had failed to provide effective treatment, dismissed her concerns and discharged her son from the service without notice or review. The Ombudsman found that Mrs A’s son had been advised to continue with the current treatment (Doxycycline) for a further 12months, despite him having already used the medication for around 2 years without effect. The reasons for this were unclear. The Health Board had not adequately considered information contained in the referral or Mrs A’s request that an alternative treatment be considered. Mrs A’s son had been discharged from the service without notice and was advised to consult the GP for another referral to be made. Mrs A and her son were inconvenienced by the Health Board’s actions and this has caused frustration for them. The Health Board agreed to, within 6 weeks, re-consider the complaint, taking into account the information provided in the referrals, and provide Mrs A with a further complaint response. It also agreed to consider whether a further dermatology appointment could be offered.

The investigation focused on Ms A’s complaint about the care and treatment she received when she attended the Emergency Department (“ED”) at Wrexham Maelor Hospital (“the Hospital”) on 26 November 2023. Specifically, the investigation considered: whether the diabetic ketoacidosis (“DKA”) Ms A experienced could have been prevented if she had been correctly triaged in the ED. The investigation also considered whether Ms A was appropriately treated on 27 November once the DKA was diagnosed. The investigation found that without knowing Ms A’s blood glucose and ketones levels at the point of triage, it would be difficult to know for sure if she was already developing DKA when she presented to the ED. The shortcomings in Ms A’s care, meant that Ms A will be left with the uncertainty of not knowing whether her experience might have been prevented had she been properly triaged. This is an injustice to her. That said, if she was in DKA and had been correctly triaged, her treatment would have followed the standard DKA protocol and therefore, Ms A could still have ended up being admitted to the Intensive Therapy Unit. Given the identified failings and ensuing uncertainty, this aspect of her complaint was upheld to this limited extent. The Ombudsman was broadly satisfied that once Ms A was diagnosed with DKA that she received appropriate treatment. However, the 6-hour delay was unacceptable, although this was due to difficulty in gaining IV access. This delay has caused Ms A and her family distress which was an injustice to her, and this aspect of the complaint was upheld. The Ombudsman recommended the Health Board provide Ms A with a written apology for the failings identified and provide evidence of the actions the Health Board said it has taken following Ms A’s complaint.

Mrs A complained that the Health Board rejected her daughter’s referral for a neurodevelopmental assessment on the grounds that she would not be seen before she turned 18, whereupon she would need to be seen, as an adult, by the Integrated Autism Service. The Ombudsman found that the Health Board had not provided appropriate support to Mrs A’s daughter. Therefore, it was agreed that, within 1 week of the decision letter, that the Health Board should contact Mrs A to enable her to share their experience and, within 4 weeks of the decision letter, that the Health Board should provide support to Mrs A’s daughter in the period before she can be assisted by the Integrated Autism Service.

The Ombudsman investigated Ms B’s complaint about the cardiology management and care that she received from Betsi Cadwaladr University Health Board’s (“the Health Board”) Ysbyty Gwynedd (“the Hospital”) between January to May 2022 and whether it was clinically appropriate, including: the delay in review of the Holter monitor (a small wearable device that records electrical activity in the heart) following her January 2022 collapse; the apparent incorrect implant of the leads into the generator of the pacemaker which resulted in an additional clinical procedure on the same day in February 2022. The Ombudsman did not uphold Ms B’s complaints. The investigation found that broadly the care and treatment provided by the Hospital’s Cardiology team was clinically appropriate and reasonable; although there were areas where clinical practice in terms of care and documentation could have been better. The investigation also found that only 1 operation took place on the day in question and this related to a displaced lead. However, the Health Board was invited to consider points of learning around the prescribing of a beta-blocker (which acts to slow the heart and suppress any rapid abnormal heart rhythm) given Ms B’s clinical presentation which included a slow heart rate.

We investigated a complaint brought by M’s mother, Mrs P, which focused on whether M’s consultations with clinicians at a GP practice (“the GP Practice”) in relation to abdominal symptoms between 11 March 2024 and 8 June 2024 were appropriately managed and whether there were any missed opportunities to diagnose appendicitis. The investigation found that there were omissions in M’s consultations with the GP practice on 6 June and, in particular, the afternoon appointment on 6 June where there was no documented abdominal examination. The failure to document an abdominal examination when there was worsening abdominal pain meant there was uncertainty as to whether there was a missed opportunity for an earlier referral to secondary care. We partially upheld Mrs P’s complaint and recommended that the GP practice within 1 month of the date of the final report apologise for the service failure identified in the report and that the report is shared at a practice meeting to discuss the shortcomings identified.

Ms B complained that while her father, Mr A, was in hospital and approaching the end of his life, the Health Board failed to take timely and appropriate action to progress Mr A’s application for Continuing Health Care (“CHC”) funding and facilitate his discharge from hospital. We found that the Health Board failed to arrange a full CHC assessment for Mr A on receipt of a completed checklist application for CHC funding. Instead, it repeatedly asked for more information which frustrated the team caring for Mr A, and his family. The Health Board also failed to consider whether it should have provided Mr A with alternative care immediately, in order to safeguard his wellbeing. Meanwhile, Mr A remained on a general ward in hospital, which was inadequate to meet his needs and appeared to have contributed to his clinical decline. Ms B’s complaints were therefore upheld. We also found a suggestion that the Health Board routinely rejects checklist applications and identified that it did not have a robust process in place to receive and progress fast track CHC applications. We considered that these issues may indicate a systemic approach that is contrary to the law and guidance on how CHC applications should be received and processed. The Health Board agreed to apologise to Ms B, review all current CHC applications to identify any who need fast track provision and to remind all CHC staff of the importance or recognising and correctly progressing checklist and fast track applications. The Health Board also agreed to draw up clear robust processes and requirements for checklist and fast track applications, implement them into use and share them with relevant other bodies for them to follow.

Miss B complained about the inpatient care and treatment provided by the Health Board’s Ysbyty Glan Clwyd (the First Hospital) and Llandudno Community Hospital (the Second Hospital) to her late father, Mr B. The investigation considered aspects of Mr B’s diabetic management, surgical clinical decision-making including about not amputating Mr B’s toe and the monitoring of Mr B’s skin condition. The investigation found that surgical decision-making was clinically reasonable and appropriate. In terms of Mr B’s diabetic management, the investigation identified that clinical and administrative failings, relating to poor documentation, contributed to Mr B experiencing more hypoglycaemic episodes than might have been the case with better management. For example, there were unnecessary delays in a referral being made to the diabetes specialist nurse team and a dietician, despite evidence of Mr B’s poor food intake. The physical and cognitive effects on Mr B, and the impact this had on the family was an injustice. It was to this extent only that this part of Miss B and the family’s complaint was upheld. The investigation also found that, although there was evidence of skin and wound monitoring and nursing intervention, documentary shortcomings meant that Mr B’s skin and wound management was not always clear. Given his arterial disease, whatever preventative care and / or wound care was provided to Mr B, might not have changed the outcome. Despite this, given the at times poor documentation, this left a degree of uncertainty around Mr B’s clinical management, which was an injustice for Mr B and the family. It was to this limited extent only that this part of Miss B and the family’s complaint was upheld. Recommendations included an apology to the family, training, changes in process and an audit with an action plan to follow up any further failings identified.

Mrs A complained that she had not been informed by Betsi Cadwaladr University Health Board that she had been removed from the surgical waiting list for a total knee replacement. The Ombudsman found that although the Health Board had sent a letter to Mrs A’s GP, it had not informed her of the decision and the reasons why, in accordance with the Rules for Managing Referral to Treatment Waiting Times guidance. The Ombudsman decided to settle the complaint without investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 6 weeks, issue a written apology and to reinstate Mrs A to the waiting list in the same place had she not been removed.

Ms A complained about the standard of care provided to her late mother, Mrs B, when she was admitted to the Emergency Department (“ED”) of Wrexham Maelor Hospital. Mrs B sadly died in the evening of the day she was discharged. The investigation considered whether during Mrs B’s 16-hour admission: • her presenting symptoms of stomach pain, vomiting and dehydration were clinically assessed and treated appropriately • she was well enough to be discharged. The Health Board had previously acknowledged and apologised for shortcomings in the standard of care provided to Mrs B, including delays in providing intravenous fluids and “corridor care” in the ED. The Ombudsman considered only the matters detailed above about the clinical assessment and the decision to discharge Mrs B. Based on clinical advice, the Ombudsman concluded that both the clinical assessment and the decision to discharge Mrs B were appropriate. The Ombudsman did not uphold the complaint.

Mrs W complained that Betsi Cadwaladr University Health Board had failed to respond to her complaint that it prescribed her medication that she is allergic to. The Ombudsman found that it had been over 6 months since Mrs W submitted her complaint and she still had not received a response from the Health Board. The Ombudsman said this caused frustration to Mrs W and decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health board’s agreement to provide an apology and explanation to Mrs W for the delay in responding to her complaint, and to issue a complaint response to her within 6 weeks.

Ms C complained that Betsi Cadwaladr University Health Board had failed to refer her for a surgical assessment, leaving her experiencing pain for longer than was necessary. The Ombudsman decided that although the Health Board had accepted and apologised for the error, it could not assess whether the error had caused harm until the surgical assessment was completed. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Ms C with a further response to her complaint within 2 months of her surgical assessment appointment.

Mr C complained about the care and treatment provided to his late father, Mr B, by Betsi Cadwaladr University Health Board between 25 and 27 November 2024. Specifically, the investigation considered whether Mr B received timely and appropriate care from hospital staff when he was in the ambulance outside the Hospital Emergency Department for an extended timeframe, and whether Mr B received timely and appropriate care when he was subsequently transferred to the Emergency Department. The Ombudsman found that whilst there were delays in Mr B’s care when he was in the ambulance outside the Emergency Department, and earlier investigation would have been desirable, it could not be concluded that it would have altered the course of his deterioration, management or outcome. The investigation also found that timely and appropriate care was provided when Mr B was subsequently transferred into the Emergency Department. The Ombudsman did not uphold the complaints.

Ms A complained that Betsi Cadwaladr Health Board (“the Health Board”) failed to fully address her concerns in its complaint response. The Ombudsman found that the Health Board failed to issue a response which fully addressed Ms A’s concerns in respect of the clinical issues she had raised, which left her with uncertainty about her treatment. The Ombudsman sought and gained the Health Board’s agreement to issue a revised complaint response, which fully addresses the clinical issues raised in the first instance, to Ms A within 1 month.

Ms A complained about Betsi Cadwaladr University Health Board’s treatment of her partner, Mr B, following an ankle replacement operation. Following Mr B’s operation the Health Board fitted a Flowtron pump to prevent blood clots. However, the pump was fitted to the wrong leg, causing excruciating pain. The Ombudsman decided that the Health Board’s complaint response was insufficient. There was no significant apology for Mr B’s experience. The response did not consider the physical and psychological impact and did not consider whether there had been a breach in the duty of care, in line with Putting Things Right requirements. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 1 month, apologise to Ms A and to provide a further complaint response.

Ms A complained about the care and treatment provided by Roseneath Medical Practice in relation to her mental health and about the action taken in relation to a private psychological assessment report. Ms A further complained about the handling of her complaint and said the Practice’s complaint response did not address her concerns. The Ombudsman found that there had been delay in the Practice responding to Ms A’s complaint and that she had not received an adequate complaint response. Ms A was inconvenienced by the Practice’s actions, which had caused her frustration. The Ombudsman decided to settle the complaint without investigation. The Practice agreed to, within 4 weeks, reconsider Ms A’s complaint, provide her with a further complaint response addressing the concerns raised with the Practice and the Ombudsman and also provide Ms A with a written apology for the failure to adequately address her concerns in its initial complaint response.

Mr A complained about the Health Board’s response to 3 GP referrals for back, hip and side pain since 2019 and the wait to by seen by the Pain Management Team. Mr A further complained about the Health Board’s handling of his complaint. The Ombudsman found that although Mr A had now been seen in the Pain Management Clinic, the injection provided was for his back only. The Health Board had not adequately investigated or addressed all the issues that Mr A had been referred for. Mr A had been discharged from the service and advised to see his GP for another referral to be made, which would inevitably result in further waiting time. The Ombudsman found that, following extensive correspondence with Mr A, the Health Board had responded to some of Mr A’s concerns. However, it had only addressed the two most recent referrals made by his GP, which did not provide an accurate picture of the position or his overall experience. The Ombudsman decided to settle Mr A’s complaint without investigation. The Health Board agreed to within 6 weeks reconsider whether a new referral from Mr A’s GP was required and to provide Mr A with a further complaint response.

Mrs R complained that Betsi Cadwaladr University Health Board stopped responding to her concerns in July 2023 and failed to respond to elements of her complaint regarding the care and treatment provided to her late father and the conduct of a doctor. The Ombudsman found that the Health Board had failed to appropriately address Mrs R’s concerns and respond to her complaint in full. This caused frustration and uncertainty to Mrs R. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise on behalf of the doctor’s conduct, provide a full complaint response, and offer a payment of £100 in recognition of her time and trouble in chasing the complaint.

Ms A complained that Betsi Cadwaladr University Health Board failed to investigate, diagnose and treat her ear nose and throat problems. She said that private consultants had recommended treatment, including surgery, which the Health Board would not provide. The assessment found that the Health Board’s view was that surgery was not clinically necessary and that correspondence from private consultants had not been shared. Given the nature of the complaint, Ms A agreed it was reasonable and appropriate for the Health Board to have an opportunity to provide comment on the correspondence. The Ombudsman sought and gained the Health Board’s agreement to consider the correspondence and comment on whether intervention was clinically necessary in Ms A’s case within 1 month.

Mr C complained that Betsi Cadwaladr University Health Board withdrew an offer of a place on a training programme because it could not fund the Sponsorship Certificate that Mr C required. The Ombudsman found that the advert and recruitment pack had not made it clear that sponsorship was not available for the position, which was contrary to the Health Board’s recruitment policy. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mr C within 1 month to apologise for not making it clear that sponsorship was not available, and offer a financial remedy of £500 in recognition of the time and trouble of applying for the position and the disappointment of having the offer withdrawn. The Health Board also agreed to review the training and advice provided to recruiting managers within 3 months.

Mrs H complained that Betsi Cadwaladr University Health Board failed to respond to a complaint she submitted in January 2025. The Ombudsman found that the Health Board failed to keep Mrs H updated for 5 months of its investigation. This caused additional frustration and uncertainty for Mrs H. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 weeks, write to Mrs H to apologise for the delay and lack of updates, to offer £100 redress payment and to issue its complaint response.

Mr A complained about the care and treatment provided by Betsi Cadwaladr University Health Board to his late wife following her admission to hospital up until she was transferred to a hospice. Mr A submitted a formal complaint to the Health Board but was dissatisfied with the response he received. Mr A complained that the response gave no true explanation of the main things asked and the delay in the response being issued. The Ombudsman found that although the Health Board had provided a response to Mr A’s formal complaint, it did not fully address the concerns raised about the care and treatment provided to his late wife and did not apologise for the delay in providing the complaint response. The Ombudsman decided to settle the complaint without investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise for the delay in issuing the complaint response and for not addressing all concerns fully within that response, and to provide a further response to address the full scope of the complaint within 6 weeks.

Mrs B complained about the care and treatment her husband, Mr B, received from the Health Board in relation to his abdominal aortic aneurysm (“AAA,” a swelling in the aorta, the artery that carries blood from the heart to the abdomen). Specifically, Mrs B queried whether the care, treatment and eventual surgery Mr B received following a scan in June 2024, was appropriate and whether the Health Board should have acted more quickly when his AAA increased in size and eventually burst open. The investigation found that the care, treatment and surgery Mr B received in relation to his AAA, following his scan, was appropriate and no failing occurred. Consequently, the complaint was not upheld.

Following assessment of the complaint, the Ombudsman found that the Health Board had appropriately responded to many aspects of the complaint, and that it was not proportionate to consider an investigation of certain aspects where nothing further could be achieved, or where there was nota significant level of injustice involved. However, there were certain key concerns raised by Mr B, relating to cannulation and peripherally inserted central catheter (“PICC”)options, and delays in dealing with certain biopsy results, that had not been addressed by the Health Board’s complaint response. Neither had the Health Board provided Mr B with a copy of Mrs B’s BRCA1 test results (indicating whether a mutation was present that increases risk of breast cancer), even after apologising and promising to do so in its complaint response some months earlier. These failings were an injustice to Mr B. The Ombudsman obtained the Health Board’s agreement to provide Mr B with a full response to the concerns still outstanding and to provide a copy of Mrs B’s BRCA1 result and an apology within 4 weeks. The Ombudsman therefore decided to settle the complaint without investigation.