PSOW Individual Decisions

Mrs A complained about the care provided to her by Betsi Cadwaladr University Health Board from November 2022 until August 2023. When Mrs A complained to the Ombudsman, she expressed dissatisfaction that when the Health Board responded to her complaint, it had not offered to discuss her concerns. The Ombudsman found that when the Health Board issued its complaint response it had failed to offer Mrs A an opportunity to discuss its response to her concerns, as required by the Putting Things Right arrangements. That amounted to maladministration on the part of the Health Board which caused Mrs A an injustice. Instead of investigating the complaint, the Ombudsman obtained the Health Board’s agreement to offer Mrs A an opportunity to discuss its response to her complaint and to apologise for not doing so in the first instance. The Health Board agreed to undertake these actions within 1 month.

Mrs C complained about the care and treatment she received from Betsi Cadwaladr University Health Board. Specifically, the investigation considered whether it was clinically appropriate that a consultant obstetrician and gynaecologist did not diagnose Mrs C with a cystocele (prolapsed bladder – where the bladder drops and pushes on the wall of the vagina) and a rectocele (when the tissue between the rectum and the vagina weakens or tears, causing the rectum to push into the vaginal wall) during appointments on 16 May, 26 June and 25 September 2023. The investigation found that the fact that Mrs C was not diagnosed with a cystocele or a rectocele during the appointments on 16 May, 25 June and 25 September 2023 did not indicate that the care she received was below the expected standards. The Ombudsman did not uphold this complaint.

Mrs A complained about the orthopaedic care and treatment she received from the Health Board. Mrs A complained to the Health Board and said that she was dissatisfied with its response. The Ombudsman decided that the Health Board had provided a response to Mrs A’s complaint, but noted that it did not fully address all of her concerns. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mrs A with a written response to address the outstanding matters she complained about, and to issue an apology for not fully addressing all parts of her complaint in its initial response. The Health Board agreed to complete these actions within 11 weeks.

Mr Q complained about the care and treatment his mother, Mrs R, received from Betsi Cadwaladr University Health Board. In particular, whether the treatment Mrs R received from November 2021 in relation to her right eye intraocular pressure (“IOP” – when the fluid pressure in the eye is high) was appropriate, and whether this caused a subsequent delay in cataract surgery which eventually took place in September 2022. The Ombudsman found that the treatment Mrs R received from November 2021 in relation to her right eye IOP was appropriate. Before Mrs R could undergo cataract surgery on her right eye, it was essential that her IOP was reduced first. The Ombudsman was satisfied that the Health Board followed relevant national guidance in addressing this issue. Once Mrs R’s IOP reduced, she was scheduled for cataract surgery. The Ombudsman concluded that the delay was unavoidable. Mr Q’s complaint was not upheld.

Ms A complained that Betsi Cadwaladr University Health Board had failed to provide her daughter with a joint Orthodontic and Restorative Dentistry appointment and treatment, since she was referred in 2021. The Health Board explained that despite continuously advertising, the position of Restorative Consultant remains vacant. It explained alternative solutions that it had explored and confirmed that it had secured some temporary locum support. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement within 2 weeks, to apologise to Ms A that she had to contact the Ombudsman, and to offer her daughter an appointment with the appropriate locum Consultant.

Mrs A complained to Betsi Cadwaladr University Health Board (“the Health Board”) about, mainly, the standard of care and treatment provided to her whilst in hospital between March and July 2023. Mrs A made her complaint in September 2024. However, the Health Board declined to investigate as the concerns were more than 12 months old. The Ombudsman agreed that many of the concerns were out of time but noted that one issue which occurred in the spring of 2024 had not been responded to. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, investigate and issue a response to the concern under the ‘Putting Things Right’ regulations and provide an apology to Mrs A for failing to do this initially.

Mrs C complained about the care and management her husband received when he attended Ysbyty Glan Clwyd (“the Hospital”). In particular, her husband not been seen by the Consultant Gastroenterologist (“the Consultant”) despite making several requests. Mrs C also referred to the lack of communication from the Specialist Inflammatory Bowel nurse (“IBD Nurse”). As part of an early resolution the Health Board agreed to apologise to Mr and Mrs C for the shortcomings in communication and for not responding to Mr C’s concerns in a user/patient friendly manner. It also agreed to offer Mr A a face-to-face appointment with the Consultant and the IBD Nurse and to explain to him his clinical pathway. It also agreed to communicate with patients in plain English.

Miss A complained that Betsi Cadwaladr University Health Board failed to fully address her concerns about her late father’s care and treatment between April and June 2023. The Ombudsman noted that the Health Board’s complaint response only sought to address Miss A’s concerns which related to the period12 May 2023 onwards. The Health Board’s failure to address the concerns relating to the earlier period amounted to maladministration, which had caused an injustice to Miss A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman obtained the Health Board’s agreement to apologise to Miss A for failing to fully address her concerns in the first instance, and to investigate and respond to those concerns. The Health Board agreed to undertake these actions within 3 months.

Mr A complained that Betsi Cadwaladr University Health Board failed to arrange an attention deficit hyperactivity disorder (“ADHD”) assessment for him and did not acknowledge this in its investigation report. The Ombudsman decided that Mr A had requested an ADHD assessment, however the necessary referral was not made. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement within 1 month to issue an apology and explanation to Mr A for not including his requests for an ADHD assessment in its report and for the delay in arranging for an assessment to take place.

Mr A complained about the standard of care provided to him in relation to the diagnosis and management of his attention deficit hyperactivity disorder (ADHD) and whether it was clinically appropriate. He was also dissatisfied with the issues raised by a letter that he had received from a psychiatrist about the shortage of ADHD medication. The Ombudsman’s investigation found shortcomings in the management of Mr A’s care including around communication and documentation. In addition, complaint handling was not as robust as it could have been. The Ombudsman concluded that as a result of the failings identified there was a missed opportunity for Mr A to have been seen sooner than in fact occurred. The Health Board agreed as part of a settlement to write and apologise to Mr A for the shortcomings identified and to reimburse the costs he had incurred in terms of his private ADHD medication. In terms of its complaint handling, the Health Board also agreed to make a time and trouble payment of £150. As part of learning lessons, the Health Board agreed to review the robustness of its decision-making process, to audit a sample of cases where a clinical decision had previously been made that there was insufficient evidence for an ADHD review/assessment and to share its findings, together with an action plan if failings are identified, with the Ombudsman’s office. Finally, the Health Board was asked to implement national guidance to improve a patient’s experience of care within its mental health service and to develop audit tools to help monitor and embed this.

Miss A complained about the length of time it took for Betsi Cadwaladr University Health Board to provide a response to her complaint. The Ombudsman found that the Health Board had taken over 12 months to provide a response to Miss A, and whilst it had apologised to her, no explanation had been provided for the significant delay. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to offer Miss A redress payment of £250 and provide her with an explanation for the delay within 2 weeks.

Mrs A complained about the lack of care and support her son had received from his Therapist as well as the Health Board’s complaint handling and the lack of response to some of her telephone calls and emails. From a complaint handling viewpoint, the Ombudsman identified instances of poor communication which were not always compatible with the Putting Things Right Guidance. She also noted issues with record keeping and the documentation of telephone contact with the complainant and her son. As part of an early resolution the Health Board agreed to apologise for shortcomings in its complaint handling as well as reminding complaint investigators of the importance of documenting telephone contact with complainants. The Health Board also agreed to review Mrs A’s case in order to identify areas of learning and improvement and to share its action plan with the Ombudsman’s office.

Ms C complained that she was unable to make an appointment with a GP Practice in the area of Betsi Cadwaladr University Health Board, which resulted in delays in reviewing her medication and issuing prescriptions The Ombudsman decided that the Practice had failed to recognise that the patient had made considerable efforts to make an appointment using the appointment booking system. The Practice had missed opportunities to remedy the situation and offer an appointment, causing an injustice to Ms C. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms C within two weeks to apologise for the failings and confirm the arrangements for booking future appointments. The Health Board also agreed to consider, within 4 weeks, the Practice’s review of the booking system to ensure that patients were able to arrange appointments with their GP.

Mr C complained about the care and treatment he received from the Health Board who outsourced care provision to a private clinic (“the Clinic”). The investigation considered whether the standard of care provided to Mr C, which commenced in January 2023, for treatment of his cataract (when the lens in the eye develops a cloudy patch) was clinically appropriate. The Ombudsman found that the operation undertaken on5 January and the subsequent procedures, care and treatment were clinically appropriate. However, the risk of posterior-capsule rupture (“PCR” – a break/tear in the posterior lens capsule)as a recognised complication was not explained to Mr C either during the pre-operative assessment appointment or on the day of surgery. This failure was unreasonable and caused an injustice to Mr C, given that he consented to the surgery without being fully informed, and then experienced a PCR during his surgery. The failure to explain this risk was not recognised as part of the Health Board or Clinic’s complaint handling. The Ombudsman therefore upheld this complaint. The Health Board agreed to the Ombudsman recommendations to apologise to Mr C for the failings identified; offer him £1000 for the injustice caused and for the time and trouble in pursuing the complaint, and to review the documentation provided to patients by all private clinics where ophthalmic treatment is outsourced, to ensure adequate risk information, including PCR, is provided and discussed prior to surgery

Ms X complained that she had been unable to register the premature birth of her child, due to the doctor recording that there were no signs of life. This was at odds with her experience at the time of the birth. The matter was referred to the Coroner who made the decision that there were no signs of life at birth and therefore the birth could not be registered. This decision was made 2 weeks after the birth because of a delay in the doctor providing a statement to the Coroner. The Health Board’s own investigation found that there were shortcomings in the documentation and communication on the day concerning signs of life. It apologised for this to Ms X and shared the learning from the events at a clinical forum. Ms X remained unhappy with the response and made a complaint to the Ombudsman. The Ombudsman noted the delay of 2 weeks between the birth and the Coroner’s decision. This was due to a delay in the doctor concerned giving a statement to the Coroner. The delay caused additional distress to Ms X and her partner, because the period of uncertainty was longer than it should have been and they had been expecting to register the birth. The Ombudsman concluded that the Health Board should have been more proactive in contacting the doctor and ensuring that a timely statement was given. This was a shortcoming and the Health Board agreed to provide Ms X and her partner, within 3 weeks, with a written apology for this delay.

Mr A complained about the care and treatment afforded to his late wife, Mrs A. The investigation considered whether Mrs A’s discharge from the Endoscopy unit, following an endoscopic retrograde cholangiopancreatography (“ERCP” – a technique used to examine the pancreas and bile ducts) and the management of Mrs A’s condition following her attendance at the Emergency Department (“the ED”) were clinically appropriate. The investigation found that whilst the decision to discharge Mrs A was clinically appropriate, the written discharge advice regarding who to contact should symptoms of pancreatitis (a condition where the pancreas becomes inflamed over a short period of time) develop, was not of an acceptable standard. The information given was confusing and led to advice being sought from services that could not assist. There were delays in ED triage, medical assessment, administering pain relief, commencing intravenous fluids and carrying out blood tests. This culminated in an overall delay in the diagnosis of acute pancreatitis. This was an injustice to both Mrs A and her family. Both aspects of the complaint were upheld. The Health Board agreed to provide Mr A with a written apology and to review this case to identify any points of learning which can be applied in future care. It also agreed to consider introducing a policy regarding the management of acute pancreatitis which should include the issue regarding re-presentations of patients after ERCP and streaming of them to either a Medical or Surgical team depending on local practice.

Complaint about the care and treatment provided by the Health Board to the complainants son prior to his death. Also complained about the response provided by the Health Board to the formal complaint as this included the incorrect date of death and dates treatments received. The Ombudsman decided that the Health Board had caused distress to the complainant due to the inaccurate information provided in its response to her complaint. The Ombudsman contacted the Health Board, which agreed to settle the complaint without an investigation. The Health Board agreed to issue an apology to the complainant for the distress caused by providing an inaccurate information in its response to her complaint and to provide a new and accurate response. The complaint concerning the care and treatment provided to the complainants son was out of time and could not be considered for investigation.

The investigation considered whether the Health Board provided adequate and timely care to manage Mr C’s trigeminal neuralgia pain(a rare condition that causes sudden, severe facial pain) between 18 and 24October 2022 and whether it was clinically appropriate that he waited 5 days in March 2023 to receive IV Fosphenytoin (a medication primarily used to control seizures). The investigation found that although the Health Board provided adequate and timely care during the October 2022 admission, given Mr C’s level and duration of pain, it would have been appropriate to consider administering a lignocaine block or high dose steroids. The clinical team made a reasonable effort to obtain IV Fosphenytoin in March 2023 once the omission in the original request was discovered however consideration should have been given to an alternative drug in the interim given Mr C’s level of pain. The Ombudsman upheld the complaint. The Health Board agreed to provide Mr C with an apology for the failings identified and two financial redress payments for the failures associated with each admission equating to £1,000. It agreed to share the report with the Neurology Department who would then meet to discuss the findings. It ensured that consideration would be given to the administration of alternative medications when the medications outlined within a care plan are not readily available locally.

Ms B complained about care and treatment provided by Betsi Calwaladr University Health Board in relation to screening received prior to being diagnosed with breast cancer. She said that the Health Board investigated her concerns before she was able to submit a formal complaint. The Ombudsman said that the Health Board’s response did not address the full extent of Ms B’s concerns. The Ombudsman sought and gained the Health Board’s agreement to within 4 weeks, apologise to Ms B for any confusion around the complaints process and set out the scope of her complaint. Then within 8 weeks of Ms B submitting her complaint, to investigate and provide a formal response to these concerns.

Miss D complained that her late aunt, Miss F’s, GP Practice incorrectly informed her that doctors did not do home visits when she rang with concerns about Miss F on 28 and 29 June 2023. The investigation found that, on the balance of probabilities, the appropriate policy was not followed by the GP Practice when Mrs D rang with concerns about Miss F on 28 and 29 June 2023. The GP Practice agreed to provide Mrs D with an apology for the failings identified and offer her a payment of £750 for the distress and uncertainty caused by these failings. It also agreed to undertake further training with its administrative staff to ensure full understanding of the Home Visit Policy and the need for a clinician to triage any requests for home visits. Finally, it agreed to review its complaint handling of this case to identify any lessons to be learned.

Mrs L complained whether, following the removal of her husband’s cancerous melanoma in 2020, he received appropriate follow-up care and whether he should have had further scans in 2022 when national guidance changed. The Ombudsman’s investigation found that after the removal of the cancerous melanoma in 2020, Mrs L’s husband’s follow-up care was appropriate. In addition, it was also appropriate that he did not receive further scans in 2022 when national guidance changed as there was no clinical evidence of recurrent melanoma disease. The complaint was not upheld.

Mr C complained about the standard of mental health care provided to his nephew, Mr B, by Betsi Cadwaladr University Health Board (“the Health Board”). Mr B, a 50 year old man, had schizophrenia and lived with and cared for his elderly mother, who had dementia. She entered full time care, leaving Mr B living alone in the family home. Sadly Mr B died after intentionally entering the sea, fully clothed. The Ombudsman’s investigation considered whether: a) The risk assessment carried out was in line with accepted clinical practice. Specifically, did it appropriately reflect the risk of harm to Mr B, including his previous history of harm. b) The support provided to Mr B by the Health Board in the community was of an appropriate standard. The Ombudsman found that: • There were shortcomings in the risk assessment and care planning process. The fact that Mr B had previously, albeit some decades before, self-harmed and attempted suicide was not reflected in his current risk assessment. It should have been. The Health Board’s review had also not identified this issue. There was also no evidence in the care plan that staff had discussed with Mr B the possibility of sharing his “risk behaviours”, outlined in his care plan, with his family so they may be able to identify these and offer additional support. • The level of support offered to Mr B was reasonable. The Health Board agreed to the Ombudsman’s recommendations including that it should: • Apologise to Mr B’s family for the identified shortcomings. • Update the Ombudsman, and Mr B’s family, about the action it took (to implement its own recommendations) following its review of the complaint. • Provide audit evidence to the Ombudsman that the standard of care plans and risk assessments was appropriately monitored. • Assess whether any additional action was needed in relation to risk assessment, communication and information sharing with family, and care planning.

Miss B complained that a Dental Practice in the area of Betsi Cadwaladr University Health Board had removed her from its patient list after she raised concerns with it about dental charges. The Ombudsman found that the dental charges were for private treatment, so fell outside of her remit. Miss B was signposted to the Dental Complaints Service for this element of her complaint. The Ombudsman also found that the Practice had not issued a full complaint response to Miss B about its decision to remove her from its patient list, and its complaints procedure for NHS patients contained incorrect and outdated information. The Ombudsman said this caused frustration to Miss B and decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Practice’s agreement to issue a complaint response to Miss B about its decision to remove her from its patient list and to update and correct its complaints procedure within 6 weeks.

Mrs X complained that Betsi Cadwaladr University Health Board had failed to provide a response to her complaint about the care provided to her late son while he was hospitalised. The Ombudsman found that the Health Board had failed to respond to Mrs X’s complaint or provide her with regular updates. The Ombudsman said this caused frustration and uncertainty to Mrs X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, issue its complaint response, provide an apology and explanation for the delay and lack of regular updates, and offer to pay £100 redress to Mrs X for her time and trouble in making the complaint to the Ombudsman.

Mrs A complained that Betsi Cadwaladr University Health Board (“the Health Board”) failed to update her or respond to her second complaint about her late daughter’s care and treatment. She said that 16 months after she submitted the complaint, the Health Board said that it was unable to respond to her concerns because her daughter’s medical records were missing. The Ombudsman decided that the missing medical records resulted in the loss of opportunity for Mrs A to have an independent investigation into her daughter’s care and treatment. She said that this caused a lasting injustice to Mrs A. The Ombudsman also decided that the Health Board’s complaint handling caused delays and frustration for Mrs A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs A for the missing records and offer a redress payment of £1,250 for the loss of opportunity to have her complaint considered. The Health Board agreed to clarify when it discovered the records were missing, take appropriate action to reduce the risk of future loss, and to continue to search for the records. It also agreed to apologise to Mrs A for the issues identified with the complaints handling and offer her £250 redress for the time and trouble taken. Finally, it agreed to respond to aspects of the complaint that were not reliant on the missing records and complete all the agreed action within 6 weeks.