PSOW Individual Decisions

Ms A complained about discrepancies between the medical records of her son, Mr A, and the investigation report written by Betsi Cadwaladr University Health Board (“the Health Board”). The Ombudsman recognised that certain discrepancies did exist. The Ombudsman sought and gained the Health Board’s agreement to within 1 month, apologise for any discrepancies, and add a note to the records to reflect the position of Ms A on issues complained about.

Mrs A complained about the Health Board’s decision to postpone her late husband’s surgery. She also complained that the Health Board failed to adequately monitor his cancer in the interim. Mrs A said the Health Board’s response to her complaint failed to respond to her questions. The Ombudsman decided that the Health Board had provided a response to Mrs A’s complaint, but noted there were aspects of the response with which Mrs A was unhappy. The Ombudsman concluded it would be helpful for Mrs A to receive the Health Board’s response to the outstanding questions and/or points raised. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement that, within 6 weeks, it would provide a further response to Mrs A to address the outstanding questions and/or points raised.

Mr A complained about the care and treatment provided to him by Betsi Cadwaladr University Health Board’s (“the Health Board”) Glan Clwyd Hospital (“the Hospital”). Specifically, whether the care and treatment provided on 26 May 2022, including the decision to discharge him, was clinically appropriate. Mr A re-attended the Emergency Department (“ED”) the next day and was diagnosed with an infected gall bladder which was subsequently removed. The Ombudsman’s investigation concluded that although Mr A did not have sepsis (a life-threatening reaction to an infection), discharge on 26 May was not appropriate. This was because a narrow focus of investigation was undertaken leading to a missed diagnosis and premature discharge from the Hospital. The injustice for Mr A was that, had a wider assessment and examination been carried out when Mr A initially attended the ED, it might have prevented his need to re-attend the following day following his discharge as well as lessened the time he was experiencing severe pain. The Ombudsman upheld the complaint. The Ombudsman’s recommendations included the Health Board apologising to Mr A for the failings identified in the report, sharing the report with the treating team as a point of learning and providing record keeping reminders to clinicians about the need for detailed notes when assessing and examining a patient.

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

Mr A complained about the care and treatment given to him by Betsi Cadwaladr University Health Board (“the Health Board”). He said that although he attended hospital for planned treatment, this did not take place. Mr A said that his condition has deteriorated and causes discomfort and pain. Mr A also complained the Health Board had not fully responded to his complaint. The Ombudsman decided that the Health Board had not provided Mr A with a full Putting Things Right (“PTR”) response to his complaint and did not reply to his follow up correspondence. The Ombudsman contacted the Health Board, which agreed to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue an apology to Mr A for the delay in responding to his complaint, pay him redress of £50 and provide a formal PTR compliant response to his complaint within 4 weeks.

Mr X complained that Betsi Cadwaladr University Health Board had responded to his complaint about the first hospital but had failed to address outstanding concerns related to the treatment he received at the second hospital. The Ombudsman found that while the Health Board had responded to his concerns regarding the first hospital, it had missed opportunities to seek comments about the treatment he received at the second hospital. The Ombudsman said this caused inconvenience and frustration for Mr X The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to within 2 weeks provide Mr X with an apology and explanation for the delay, and to issue a further response to the outstanding concerns related to the treatment he received at the second hospital.

Mr H complained about not receiving a medical appointment to remove a lump from his head. Mr H complained to the Health Board noting on the top of his letter that it was a formal complaint. The Ombudsman found that Mr H had been referred as a routine patient and that he is currently on a waiting list. There was no evidence of maladministration concerning either his referral or the management of the waiting list. However, the Ombudsman was concerned that although Mr H had made a formal complaint, he had not received an appropriate response, instead he was provided with a generic and out of date response. The RB has agreed to issue Mr H with a formal response to his original complaint within 20 working days.

Ms X complained that the Surgery had failed to contact her to discuss her ongoing health checks and had not responded to the complaint she made in September 2023. The Ombudsman decided that there had been a failure by the Surgery to respond to the complaint and this had caused frustration and uncertainty for Ms X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Surgery to apologise to Ms X and provide her with a complaint response which addresses her original concerns within 4 weeks. The Surgery also agreed to pay Ms X financial redress of £75 in recognition of the delays.

Mr X complained that Betsi Cadwaladr University Health Board (“the Health Board”) had not fully responded to his concerns about the management of his ongoing care and treatment and delays for a surgical procedure. The Ombudsman’s assessment found that the Health Board had not provided Mr X with information regarding management of his ongoing care and treatment including the status of a referral. Mr X had also not received a full response to his complaint. The Health Board agreed to, within 4 weeks, provide a full complaint response and update regarding the status of the referral including confirmation of current responsibility for his care.

Miss A complained about various issues relating to the care and treatment provided to her in respect of her mental health. The Health Board had met with Miss A to discuss her concerns and subsequently wrote to her to confirm what had been discussed and what it considered had been agreed. The Ombudsman decided that the Health Board had not properly investigated and responded to Miss A’s concerns under the Putting Things Right (“PTR”) arrangements. Instead of investigating the complaint, the Ombudsman sought and gained the Health Board’s agreement to apologise to Miss A for failing to offer her a formal investigation and to investigate and respond to her complaint under the PTR arrangements. The Health Board agreed to undertake these actions within 3 months.

Mrs X complained that Betsi Cadwaladr University Health Board’s complaint response did not address her concerns. The Ombudsman found that Health Board had agreed to reinvestigate Mrs X’s complaint, however it had failed to provide her with a complaint response. She said this caused frustration to Mrs X. She 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 X with an apology and explanation for the delay, issue its complaint response and offer a £50 redress payment in recognition of the delay, time and trouble, and need to approach the Ombudsman.

Dr C complained about the care and treatment she received from Betsi Cadwaladr University Health Board (“the Health Board”) before, during and after the birth of her first child on 16 July 2022. The following matters were investigated: · Whether Dr C should have been diagnosed with pre-eclampsia (a condition which affects some pregnant women and which can lead to serious complications) and hypertension (high blood pressure) earlier in her pregnancy and if this was managed appropriately. · Whether during labour, Dr C’s pain was managed appropriately and whether it was appropriate to carry out her episiotomy (a cut between the vagina and anus) and if consent was obtained. · Whether Dr C was discharged appropriately and if the refashioning of her perineum should have been carried out sooner. · Whether Dr C received appropriate support from health workers following her return home. The investigation found that Dr C was not diagnosed with pre-eclampsia and hypertension until she presented in labour, and it was managed appropriately. During labour, Dr C’s pain was managed appropriately, and it was appropriate to carry out an episiotomy and consent was obtained. Dr C was discharged correctly, and the refashioning of her perineum could not have been carried sooner due to infection. The Ombudsman did not uphold these complaints. However, the Ombudsman did find that whilst Dr C received appropriate support from health workers, improved monitoring of her perineum following the birth and better communication with her regarding possible complications, following the episiotomy might have provided reassurance to Dr C and improved her bonding and confidence with her child. Therefore, this part of the complaint was upheld.

Mr A complained about the waiting times for planned care. He complained that Betsi Cadwaladr University Health Board (“the Health Board”) failed to respond to his complaint within the agreed timescales, i.e., 30 working days. The Ombudsman decided that the Health Board had responded to Mr A’s complaint, but there was a delay which amounted to 52 working days. The Ombudsman noted the Health Board had failed to apologise to Mr A for its delay. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement that, within 6 weeks, it would provide a written apology to Mr A, for the delay in responding to his complaint.

Ms S complained that Betsi Cadwaladr University Health Board failed to provide a response to her complaint, which she made to it in December 2023. The Ombudsman found that the Health Board had not issued a complaint response to Ms S. She said that this caused frustration and uncertainty to Ms S. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms S with an apology for the delay in issuing a complaint response, offer Ms S £150 in recognition of her time and trouble in making a complaint to the Ombudsman and to issue a complaint response within 6 calendar weeks.

Mr A complained about the care and treatment provided to his late father Mr B, at Glan Clwyd Hospital from February to April 2023, when he sadly died. The Health Board had responded to most of the concerns raised in the initial complaint, but failed to investigate and respond to concerns about nursing care in the last days of Mr B’s life. Instead of investigating the complaint, the Ombudsman sought and obtained the Health Board’s agreement to apologise to Mr A and to investigate and respond to the outstanding concerns. The Health Board agreed to undertake these actions within 3 months.

Mr and Mrs A complained that Betsi Cadwaldr University Health Board provided them with their relative’s clinical records and accepted their complaint about her care and treatment, but that it would not share the outcome of its investigation. Mr and Mrs A said their relative did not have capacity. The Health Board said that it did not have correct authorisation to disclose the information to Mr and Mrs A. The Ombudsman decided that it was unclear how the Health Board had decided what information it could disclose to Mr and Mrs A about their relative. Although the records had been provided, the Health Board said that it required evidence of a Lasting Power of Attorney (“LPA”) for Health and Welfare as authorisation to disclose the outcome of the investigation. The Ombudsman decided that this was unreasonable as it is not possible to produce an LPA if it was not made in advance of a person lacking capacity. The Ombudsman decided it was unclear how Mr and Mrs A’s relative’s rights could be exercised if the outcome of the investigation was not shared. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to review its decisions relating to the provision of information to Mr and Mrs A in line with the Mental Capacity Act and provide a formal response to them with clear explanations. To review its procedure for deciding on the disclosure of information for people representing a person who lacks capacity in line with the Mental Capacity Act. To consider producing guidance for complainants/individuals requesting information on behalf of a person who lacks capacity, which is clear and in line with the Mental Capacity Act. The Health Board agreed to undertake the action within 20 working days.

Mrs G complained about the standard of nursing care provided to her late mother, Mrs F, when she was an inpatient on a rehabilitation ward. Mrs G raised concerns about access to fluids, medication and occasions when Mrs F was not cared for in a dignified way. Mrs G did not feel that Betsi Cadwalader University Health Board (“the Health Board”) had properly answered her queries. The Health Board, following its complaint investigation, accepted that there were aspects of care that had fallen below an acceptable standard and identified areas for improvement action. These were: · Medication management · Ensuring dignity in care is maintained at all times · Documentation of clinical MDT meetings. The Ombudsman requested an update about the action that the Health Board had taken on these points. In addition, the Ombudsman’s view was that the Health Board had not properly responded to Mrs G’s complaint about fluid management and assistance with drinking. The Health Board agreed, within 4 weeks, to: 1. Confirm and provide evidence to the Ombudsman’s office of the action taken on the learning points following its own complaint investigation. 2. Review the issues raised by Mrs G about ensuring hydration and the specific assistance given to Mrs F with drinking and provide a further response to Mrs G addressing this issue. This response will also include confirmation of the action the Health Board has taken to address the 3 learning points from its original investigation.

Mr B complained that Betsi Cadwaladr University Health Board had not referred him for a CT scan of his head, which was discussed during an appointment with the Community Psychiatric Nurse. The Ombudsman decided that the Health Board had not communicated clearly with Mr B following his appointment with a Community Psychiatric Nurse that he did not meet the threshold for Tier 2 mental health services. This led to confusion about how he could access a CT scan. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement that within 30 working days, it would apologise to Mr B that he was not clearly communicated with following the assessment, and outline any learning identified to ensure that letters clearly communicate who is responsible for any onward referrals discussed.

Miss A complained that Betsi Cadwaladr University Health Board failed to issue a response to her email regarding assessment of her daughter, sent on 30 December 2023. Miss A said her daughter had not been assessed for various neurodevelopmental disorders, such as autism, PDA, ADHD, dyslexia, dyscalculia and dyspraxia. As a result, she had not had the benefit of early diagnosis, treatment and support. The Ombudsman found that the Health Board had failed to issue a response. She said this caused frustration and uncertainty to Miss A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Miss A with a written response to her email, together with a written apology for the delay in doing so.

Mrs L complained about the care and treatment her late mother, Mrs K, received from the Health Board between January 2021 and her death on 31 January 2022 from biliary sepsis (a serious infection of the bile ducts). In particular whether monthly blood tests were an appropriate way to monitor her condition from January 2021, and the follow-up care for Mrs K following a biliary stent in November 2021. Mrs K had pancreatitis (inflammation of the pancreas) in January 2021. An ultrasound scan was undertaken but the Ombudsman found that the scan was inadequate as Mrs K’s bile duct was not visible, so it could not be seen whether gallstones were present. The Ombudsman found that given Mrs K’s clinical history the most likely cause for pancreatitis was gallstones, but the Health Board had concluded it was steroid induced pancreatitis despite the scan being unclear. The failure to identify Mrs K’s gallstones in January 2021 meant her condition remained untreated. In August, Mrs K developed other symptoms. Scans undertaken in the autumn showed evidence of a blocked bile duct which required surgery in November. The Ombudsman found that she should have been treated sooner and these were further missed opportunities by the Health Board to identify the seriousness of Mrs K’s condition. The surgery did not fully resolve Mrs K’s condition, and she sadly died in January 2022. The Ombudsman concluded that if Mrs K had been treated appropriately at the outset, her pancreatitis would have been treated successfully and her deterioration and death may have been prevented. This was a grave injustice to Mrs K and her family. The Ombudsman also found little to no evidence that the seriousness of Mrs K’s condition was appropriately communicated in October to her and her family either before or after treatment. Public Services Ombudsman for Wales: Investigation Report The Ombudsman found that although the surgery in November was carried out too late for Mrs K, the procedure was performed to t

Mrs C complained about the care provided to her daughter, Ms A, by the Health Board. The investigation considered whether Ms A’s discharge from hospital on 21 November2022 was clinically appropriate. The Ombudsman found that Ms A was discharged without a full assessment of her swallowing difficulties, following referral to the Speech and Language Therapy (“SALT”) team. It was not clear whether she could tolerate the oral antibiotic medications provided, and she was discharged without a fluid thickener prescription that may have made a difference to Ms A’s ability to tolerate that medication. There was also no apparent discharge co-ordinator or records to demonstrate whether Ms A had any further support needs prior to her discharge. While this may not have made a difference to the eventual outcome, this was an injustice to Ms A and her family. Ms A’s discharge was unacceptable, as the appropriate care and consideration was not given to her circumstances at that very challenging time. Therefore, the complaint was upheld. The Ombudsman recommended that the Health Board apologise to Ms A’s family for the failures identified, and ensure that the Ombudsman’s report and its findings were shared with clinical staff, to enable staff reflection on the failing identified. She also recommended that the Health Board provide evidence to demonstrate its implementation of the improvements and actions it said had been taken, when it investigated Mrs C’s complaint.

Mr B has age related macular degeneration in both eyes (a condition that affects the middle part of your vision). He complained that although his treatment plan included him being seen at intervals of between 4-8 weeks (dependant on his presentation and Ophthalmologist advice at each appointment), he was not provided with appointments at the frequency required, due to Health Board resourcing issues. He was concerned that the lack of appropriate appointments would lead to a deterioration of his eyesight. He wanted the Health Board to ensure that treatment was carried out at the required intervals. The Health Board agreed to commit to a plan of treatment for Mr B within 1 month, setting out how it will provide ongoing care in line with Mr B’s Ophthalmologist’s expectations. It would also communicate the treatment plan to Mr B within this timeframe. The Ombudsman considered this to represent an appropriate outcome and closed the case on this basis.

Mr B complained that the Health Board had not responded to all the questions that he had raised with the GP Practice. He also was unhappy with the Health Board’s handling of his complaint, including the time taken to provide a response. He referred to the effect this had on him. The Ombudsman was critical of the Health Board’s complaint handling and its complaint response. The Ombudsman noted that the Health Board had not properly taken into account its freedom of information (FOI) duties. It had also not considered the need for reasonable adjustments under the Equality Act 2010, given that Mr B had informed the Health Board that he had autism and dyslexia and what this meant in terms of his needs. Given the stress that the Health Board’s poor complaint handling had caused Mr B, the Ombudsman was satisfied that this had caused Mr B an injustice. The Health Board agreed to apologise to Mr B for the failings identified, and pay Mr B financial redress payment of £250 for the inconvenience and time and trouble caused to him by the Health Board’s complaint handling failings. It also agreed to look at lessons to be learnt from Mr B’s case around FOI and reasonable adjustments, and to take other measures including appropriate FOI training and improved documentation around reasonable adjustments.

Ms X complained about the care her late father, Mr Y, received from Betsi Cadwaladr University Health Board at the Acute Medical Unit at Ysbyty Glan Clwyd (“the Hospital”) in June 2022.  Her concerns included whether her father’s nutritional intake was managed appropriately, including the referral to the Speech and Language Team (“SALT”).  Whether his pain was managed appropriately, including the referral to Palliative Care and if his risk of falls was managed appropriately.  Finally, whether his management shortly before his collapse on 9 June 2022 was appropriate. The Ombudsman’s investigation found that Mr Y’s nutritional needs were not met.  The nutritional screening tool, which would have shown he was at high risk of malnutrition was not completed, no referral was made to a dietician and a SALT referral was not made until the day Mr Y died, a week after his admission.  No record was kept of his nutritional intake, and on occasions he was not offered prescribed nutritional supplements.  The Ombudsman upheld this part of the complaint. The Ombudsman found that on the whole Mr Y’s pain was managed appropriately, he was given frequent pain medication and there were no records of uncontrolled pain.  A referral to Palliative Care was made promptly when it was decided that further treatment for his cancer was unlikely.  This part of the complaint was not upheld . The Ombudsman found that the falls risk assessment was not accurately completed; it did not identify risk factors and therefore Mr Y’s risk of falls was not managed appropriately.  This part of the complaint was upheld. The Ombudsman found that Mr Y’s care on 9 June was generally of a reasonable standard.  He was reviewed by doctors when necessary, nursing staff attended to him many times in response to his requests to open his bowels, and regular routine checks were carried out.  However, Mr Y was not given his prescribed laxatives the previous day, and this, indirectly, might have led to his apparent attemp

Mrs E complained that the Health Board’s treatment and care of her father, Mr D, fell below a reasonable standard. Specifically, Mrs E complained that Mr D was discharged on 12 October 2021 without a follow-up plan in place, which meant his pressure sore remained untreated. She also complained that the decision to carry out a barium swallow procedure (X-ray pictures taken after liquid containing a metallic compound is swallowed) was not reasonable, given Mr D had difficulties swallowing and was at risk of inhaling the liquid. Finally, she was concerned that a discussion about a Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) decision was held with Mr D without the support of his family and without a diagnosis. The investigation found that the Health Board failed to arrange a referral to the District Nursing (“DN”) team regarding Mr D’s pressure sores during the period of his discharge. Consequently, he suffered pain and discomfort, although the sores did not become worse. This point was upheld. The investigation also found that the administration of the barium swallow procedure was reasonable in itself, but it was unlikely the risks had been explained to Mr D, so he was unable to consent fully. This point was upheld to that extent. Finally, the investigation found that although the DNACPR decision was made without the involvement of Mr D’s family, the clinician did make several attempts to contact Mr D’s son. This point was not upheld. The Ombudsman recommended that the Health Board should provide Mrs E with a written apology for the failings identified in this report. She was satisfied improvements had already been made regarding referrals to the DN team, but said the Health Board should review its arrangements for recording discussions with patients regarding radiological procedures and document its outcome.