PSOW Individual Decisions

Mr A complained that Betsi Cadwaladr University Health Board had failed to properly consider his complaint that a member of ITS staff had offered to assist him with his DVLA application but had not done so. The Ombudsman found that, following the Health Board’s initial complaint response in which it said no discussion about a DVLA application had occurred, Mr A had emailed further information to it. The Health Board failed to respond to Mr A’s further information. The Ombudsman said this caused frustration to Mr A and decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr A for failing to respond appropriately to the further information he provided, and to issue a further complaint response to him within 4 weeks.

Ms A complained that Betsi Cadwaladr University Health Board (“the Health Board”) did not inform her that anti-depressant medication could be difficult to come off, with potentially difficult side effects. The Ombudsman decided that the Health Board had held discussions with Ms A about the difficulties of coming off the medication. However these discussions had taken place after the medication had already been started. The Health Board’s complaint response did not address the concern that no conversation had taken place before the medication was prescribed. 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 provide an updated complaint response addressing her concern about not being informed of the difficulties in coming off the medication before it had commenced.

Mrs A complained about delays from Betsi Cadwaladr University Health Board (“the Health Board”) in diagnosing her congenital condition. Mrs A said that the Health Board did not respond to the further questions she posed in a letter of May 2025. The Health Board told the Ombudsman that it had not previously had sight of the letter, but that it would be willing to provide a response to Mrs A’s questions. The Ombudsman sought and gained the Health Board’s agreement, within 11 weeks, to provide Mrs A with a response to the questions posed within the letter dated 6 May 2025.

Mr C complained that a GP Practice refused to visit his partner, Ms A, at home for 6 months, despite her deteriorating health. He complained that when a home visit was undertaken, the assessment of his partner was inadequate and the referrals that were made were not appropriate. The Ombudsman found that the Practice did not take adequate steps to assess Ms A following concerning blood test results and failed to recognise that her health conditions prevented her from attending the surgery. This may have contributed to a delay in diagnosing cancer and providing treatment, albeit it was sadly unlikely that this would have changed the outcome. The Ombudsman found that the assessment carried out during a home visit that was undertaken, and the referrals that were made, were clinically appropriate. The Ombudsman upheld Mr C’s complaint that the assessment of Ms A’s need for a home visit was not clinically appropriate and did not uphold Mr A’s complaint about the care that was provided during the home visit. The Practice agreed to apologise to Mr C and provide feedback to the doctor involved within a month. The Practice also agreed to review its Home Visiting and Complaints Policy within 3 months.

Ms A complained that the Practice had not fully responded to her complaints regarding care and treatment supplied over a number of years. Following assessment of the complaint, the Ombudsman decided that some of Ms A’s complaints were out of time for consideration. Ms A had, however, approached the Practice with more recent complaints which had not been addressed. The Ombudsman sought and gained the Practice’s agreement to respond to Ms A’s more recent complaints, provide an apology and an update on her current care and treatment. The Practice agreed to do so within 30 working days.

Ms A complained about the care and treatment provided to her father, by the Health Board, between November 2023 and September 2024 and that the response provided to her complaint did not address all of her concerns. The Ombudsman found that, although the Health Board had conducted an investigation into the complaint, the report provided to Ms A did not fully address the concerns raised about her father’s discharge from hospital in September 2024. In addition, Ms A remained unclear about aspects of the action taken by the Health Board in response to its investigation findings. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Ms A with a full response to outline its investigation findings within 4 weeks. In addition, it would provide clarification about the action taken following its investigation and provide an apology for not addressing all the concerns raised in its previous response.

Mr A complained that Betsi Cadwaladr University Health Board (“the Health Board”) had not provided appropriate care and treatment to him following a referral by his GP. He also complained that the Health Board had not responded to a complaint submitted on his behalf by his local Member of the Senedd (“the MS”). The Ombudsman found that, although the Health Board had responded to the complaint submitted by the MS directly, Mr A remained unclear of the plan regarding his care and treatment. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, provide Mr A with a response directly, to include an update on the status of all current referrals and address the concerns raised regarding considerations for his care and treatment. Therefore, the Ombudsman considered the matter settled based on the action the Health Board has agreed to take and did not commence an investigation.

Ms A complained that Betsi Cadwaladr University Health Board (“the Health Board”) did not take responsibility for investigating her complaint about her removal from the patient list of a GP Practice within the Health Board’s area. The Ombudsman found that, although the Health Board had responded to Ms A’s queries about the complaint investigation, it had not provided a formal response and Ms A remained unclear about the rationale for its investigation not going further. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, provide Ms A with a formal response outlining the action taken by the Health Board when handling the complaint submitted in September 2024. It agreed to include in the response the rationale for the decisions made regarding the Health Board’s investigation of the complaint.

Mr A complained about Betsi Cadwaladr University Health Board’s (“the Health Board”) handling of his complaint, and his request for a second opinion from an alternative venue. The Ombudsman found that it was unclear why the Health Board did not proceed with Mr A’s complaint on 5 November 2024, and that it did not explain what it required to proceed, or explain that his complaint had been closed. She also found that an offer of a second opinion from an alternative venue had been made in writing, which had not been fulfilled. She found that 2 letters sent to Mr A in August 2024 had been contradictory, and no explanation had been offered for this. She found that the Health Board had not explained to Mr A that he would be offered a second opinion initially from the same service. And finally, she found that the Health Board gave contradictory information to Mr A as to whether he was entitled to a second opinion. The Ombudsman sought and gained the Health Board’s agreement, within 8 weeks, to contact Mr A and apologise for not communicating clearly about what it required to proceed with his complaint, or for explaining that his complaint had been closed, apologise for contradictory information given in letters received in August 2024, and for not sending a Part 3 Mental Health Measure letter, apologise for not explaining to Mr A that a second opinion was being arranged for the same venue, and apologise for the conflicting information given to Mr A about his entitlement to a second opinion. The Health Board also agreed to, within 12 weeks, arrange for a second opinion at an alternative venue as offered in the letter of 28 February 2025.

Mrs X complained that Betsi Cadwaladr University Health Board had agreed to respond to her further concerns following the investigation report, however, it failed to provide this response. The Ombudsman found that the Health Board had failed to provide this final response to the complainant. The Ombudsman said this caused uncertainty and frustration for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 6 weeks, provide the final response which will include an apology for the delay and an explanation as to why this happened.

Mr X complained that Betsi Cadwaladr University Health Board had failed to provide a complaint response regarding the care and treatment provided to his late mother. The Ombudsman found that there had been a delay in the Health Board issuing its response, which she said caused frustration to Mr X. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr X and explain the reasons for the delay, to offer him a redress payment of £150, and to issue its complaint response within 4 weeks.

Mr C complained about the care and treatment he received from Betsi Cadwaladr University Health Board (“the Health Board”). Specifically, whether his colorectal prolapse had been managed appropriately by the Colorectal Team from the time of initial referral in February 2022 to May 2024. The investigation found that Mr C’s colorectal prolapse had been managed appropriately. The impact of the COVID-19 pandemic meant there was a substantial waiting list for surgery. Mr C’s reported symptoms at a consultation review in April 2023 indicated that it was appropriate to undertake additional investigations rather than proceed with the surgery. Subsequently, the appropriate investigations were requested and those that could be undertaken by the Health Board were done in an appropriate timeframe. Due to an email error, a referral for a proctogram (an examination of the lower bowel and rectum using X-rays to show how the rectum functions during the emptying of the bowels) was not received until the error was rectified 5 weeks later, causing a delayed response. However, this did not cause a significant injustice. The Health Board has been hampered by the inability to find an alternative health board/trust to undertake an investigation which is not available locally but is deemed necessary. Whilst communication over the latter period of care considered could have been improved, we were not persuaded that it constituted inappropriate care or that Mr C had suffered a significant injustice as a consequence. The investigation did not uphold Mr C’s complaint.

Mr C complained about the care and treatment he received from Betsi Cadwaladr University Health Board (‘the Health Board’) following a back/rib injury he sustained on 6 June 2024 whilst on a rollercoaster at a theme park. Mr C said the Health Board missed opportunities to diagnose his spinal fracture and that a physiotherapist failed to manage his back pain appropriately. The investigation found that appropriate care was provided to Mr C when he presented to the Emergency Department at the hospital on 7 June 2024 and that there were no missed opportunities to diagnose his spinal fracture. The investigation also found that appropriate physiotherapy care was provided to Mr C who was diagnosed with a relatively minor, stable fracture. The Ombudsman did not uphold this complaint

Mr C complained about the care and treatment his wife, Mrs C, received from the Podiatry and Orthotics Department (‘the Podiatry Department’) and the Health Centre based within Betsi Cadwaladr University Health Board (‘the Health Board’). The investigation considered the following: Whether the assessment, diagnosis, advice and follow up care provided by the Podiatry Department in August 2023 was clinically appropriate. Whether the GP’s referral to the Podiatry Department on 27 July 2023 contained sufficient clinical information to enable it to assess the urgency of the referral appropriately. Whether the GP who attended Mrs C on 17 August 2023 took appropriate clinical action in response to her reported and observed symptoms. The investigation found that the care provided to Mrs C by the Podiatry Department was appropriate. The GP’s referral to the Podiatry Department in July contained sufficient information to allow an appropriate assessment of its urgency and the GP that attended the home visit on 17 August took appropriate clinical action in response to Mrs C’s reported and observed symptoms. The complaint was not upheld.

Mr C complained that Betsi Cadwaladr University Health Board had not adequately considered his relative’s referrals or provided the support required, which resulted in the family having to seek private healthcare. The Ombudsman decided that the Health Board’s response did not address the full scope of Mr C’s complaint, as it focused on only two of the referrals that had been received. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue a full response to Mr C’s complaint within 6 weeks.

Mrs C complained about the care and treatment she received from the Health Board. The investigation considered whether the care and treatment offered in respect of Mrs C’s elbow injury, sustained in February 2023, was appropriate; specifically whether it was appropriate that the complete tear in the common flexor (elbow) tendon was not identified before 31 July 2023. The investigation found that a series of delays hindered Mrs C’s patient journey and that her pain and discomfort could have been lessened sooner with the application of a brace, had the extent of her injury been diagnosed earlier. The complaint was therefore upheld. The Ombudsman recommended that the Health Board apologise to Mrs C and pay her £500 in recognition of the emotional impact of its failings. She also recommended that several Health Board staff reflect on the findings of the investigation and identify lessons learned.

Miss C complained about whether opportunities were missed to make an earlier diagnosis of attention deficit hyperactivity disorder (“ADHD” – a condition that affects people’s behaviour, making them restless, inattentive and impulsive) and whether the prescription of antipsychotic medication was managed appropriately. The investigation found that appropriate referrals for ADHD assessments were made. This part of Miss C’s complaint was not upheld. Whilst the prescription of antipsychotic medication was appropriate, there were failings in communication with Miss C by a Community Psychiatric Nurse (“the CPN”) regarding her treatment. A review of Miss C’s condition by a psychiatrist should also have been sought sooner. These failings are an injustice to Miss C. She was distressed by the Health Board’s communication and will be left with lasting uncertainty regarding what the outcome may have been had she undergone an earlier review by a psychiatrist. This part of Miss C’s complaint was upheld. The Health Board agreed to the Ombudsman’s recommendations to apologise to Miss C and offer her a payment of £200 for the uncertainty and distress caused to her. The Health Board also agreed to remind the CPN of the importance of ensuring that patients understand what they can expect from primary care mental health services and communicating their right to referral to secondary care.

Mr A’s complaint related to care and treatment provided to his late mother, Mrs B, by the Ear Nose and Throat departments of Wrexham Maelor and Glan Clwyd, between August and November 2023. Mr A referred to failings in communication, medical assessment, and the overall standard of care, and he was dissatisfied with Betsi Cadwaladr University Health Board’s (“the Health Board”) complaint response. The Ombudsman noted that the Health Board had not been given an opportunity to respond to some of the specific points that Mr A had raised in his complaint to the Ombudsman. It agreed as part of an early resolution to provide a written response to Mr A on those points which would centre on Mrs B’s management, care and diagnosis as well as communication.

Complaint about the care and treatment provided by the Practice and in its response to her complaint, it had not addressed her concerns. The Ombudsman decided that there had been a failure by the Practice to respond fully to the concerns raised by the complainant in its response to her complaint. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Practice to issue a further complaint response and to offer an in-person meeting. The Practice agreed to do this within 4 weeks of the Ombudsman’s decision.

Mr A complained about the inconsistencies in different specialist scan results where a pancreatic 8mm tumour had been found on the initial CT scan but not on the follow-up MRI scan. Given that Mr A had raised concerns around his management it was agreed that, as part of a settlement, Mr A would meet relevant clinicians, a representative from the Health Board’s governance team and the Clinical Director to discuss all of his concerns with the aim of reaching a resolution.

Mr A complained that a delay in Betsi Cadwaladr University Health Board carrying out a second procedure to remove a polyp resulted in it becoming cancerous. The Ombudsman decided that whilst the Health Board’s response to the complaint concluded there was no qualifying liability, as the correct treatment procedures were followed, it did not take account that this was significantly later than it should have been. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to reconsider whether there is qualifying liability in relation to Mr A’s complaint, and if the Health Board concludes there is, proceed to consider the matter under the financial provisions of Putting Things Right. The Health Board agreed to complete this within 6 weeks of the Ombudsman’s decision.

Mrs C complained about the care and treatment provided to her late mother, Mrs A, during her admission to the Emergency Department (“ED”) of Ysbyty Glan Clwyd (“the Hospital”) between 21 and 24 January 2023. In particular, the investigation considered whether there was a delay in the provision of a bed, antibiotics, pain relief and a delay in clinical review. The investigation found that the care and treatment provided to Mrs A during her admission to the ED between 21 and 24 January 2023 fell below an appropriate level. It was found that there was a delay in provision of a bed for Mrs A, in administering antibiotics and pain relief and in carrying out a clinical review. The Ombudsman found that the significant deficiency in this case was the failure to escalate the surgical team’s non-response to a more senior clinician. This failing meant that Mrs A did not get timely clinical intervention. Had this occurred, in all likelihood, this could have led to clinical intervention sooner and with a more senior surgical review. Had this happened it is likely that the severity of her illness and the need for antibiotics would have been recognised sooner. It is possible, although not certain, that if Mrs A had received earlier antibiotics, her outcome might have been different. The delay in administrating pain relief would have caused Mrs A additional distress. The Ombudsman considered that the failings in this case were fundamental, went to the heart of good clinical care, and to that extent, were unacceptable. The service failings identified, caused a significant injustice to Mrs A and her family and they will always have to live with the knowledge that opportunities were missed in their mother’s care and management. The Ombudsman therefore upheld the complaint. The Ombudsman made a number of recommendations, which were accepted by the Health Board. These included apologising to Mrs C and family for the failings identified by the investigation as well as developing protocol

Mrs X complained that Betsi Cadwaladr UniversityHealth Board had failed to respond to her complaint satisfactorily, and whenshe approached them with additional concerns, it failed to provide a furtherresponse. The Ombudsman found that the Health Board failed toissue its further response. She said this caused uncertainty andfrustration to Mrs X. The Ombudsmandecided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’sagreement to, within 2 weeks, provide Mrs X with a written apology andexplanation for the delay, and to issue its further response.

Mrs A complained that Betsi Cadwaladr University Health Board had failed to provide a complaint respond to a complaint her husband, Mr A, had submitted in respect of the care and treatment his father, Mr B, had received from the Health Board. The Ombudsman decided that the Health Board had enquired whether Mr A held Lasting Power of Attorney for Mr B, as Mr B was subject to a Deprivation of Liberty order, but it had not sent a formal response outlining the reasons why it considered Mr A was not a suitable person to raise the complaint. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement, that within 1 month, it would send Mr A a formal response, explaining its reasoning.

Ms A complained about the care she received from Betsi Cadwaladr University Health Board (“the Health Board”) and Liverpool University Hospitals NHS Foundation Trust (“the First English Trust”). Her concerns included her management and care following surgery for her inflammatory bowel disease in 2019, whether she was properly consented for surgery to address her fluid collections and pelvic infection in March 2022, as well as the post-operative care and treatment and the handling of her complaint. The investigation found that following Ms A’s surgery in 2019 the Health Board’s management of her post-operative fluid collections was appropriate, but there were failings in the colorectal care provided by the First English Trust. The Ombudsman noted that Ms A should have been reviewed and monitored more closely, although it could not be definitively said that this would have prevented sepsis. The Ombudsman also found issues with gynaecological referrals made to another NHS Trust, the appropriateness of an investigative procedure and the lack of preventative antibiotics given. These failings led to persistent infection and ill health for nearly 3 years before definitive surgical treatment in March 2022. The investigation identified shortcomings in the consent process, and the Ombudsman concluded that Ms A did not give informed consent for the surgery in March 2022. This raised human rights considerations, particularly regarding personal autonomy and the right to respect for private and family life. The injustice for Ms A included not having an opportunity to reconcile herself to the likely outcome of the surgery or to explore options to have biological children in the future. The impact on Ms A, both physically and psychologically, was significant. The investigation also highlighted a failure to provide information and advice about hormone replacement therapy, leaving Ms A to experience menopausal symptoms without clear management. In respect of the handling of Ms A’s co