PSOW Individual Decisions

Ms T complained about how a doctor communicated with her at Wrexham Maelor Hospital. Ms T said he was rude, dismissive, did not listen and did not answer her questions. Ms T also complained that there were delays in the Health Board issuing a complaint response and that she was not kept updated. The assessment of Ms T’s complaint identified that the Health Board’s complaint response included an apology from the doctor, who confirmed he will be reflecting on the concerns raised going forward. The Ombudsman considered these actions were reasonable. It also identified that there were delays in the handling of Ms T’s complaint including that her initial complaint, made on 19 February 2024, was not responded to so she had to submit a further complaint on 20 March 2024. She was also not kept updated. The Health Board agreed to, within 4 weeks, issue a further complaint response to Ms T. This would include an investigation into the handling of her complaint. It would also include an apology for the delay in issuing the response and for not updating her during this time. The Ombudsman considered the action agreed was reasonable and Ms T’s complaint was closed on this basis.

Mrs B complained about her husband, Mr B’s, care and treatment by Betsi Cadwaladr University Health Board (“the Health Board”). Mr B went to the Emergency Department (“the ED”) at Wrexham Maelor Hospital in April 2022 with urinary retention. My investigation considered whether his symptoms should have led to an urgent suspected cancer referral. My investigation also considered whether the Health Board’s management of Mr B’s care, between April 2022 and February 2023, was clinically appropriate and in line with the suspected cancer pathway. I considered if the Health Board’s communication with Mr and Mrs B, including sharing information about investigations and treatment plans, during this time was appropriate. I also considered if the likely waiting time for a biopsy in August 2022 was reasonable. Finally, my investigation considered the Health Board’s complaint handling of this case. My investigation found that Mr B was treated appropriately when he attended the ED in April 2022 and this complaint was not upheld. I found that, whilst there were elements of Mr B’s care that were clinically appropriate, Mr B was denied potentially curative surgery. The decision not to offer surgery was based on the view his cancer had spread. However, there was uncertainty about whether this was the case and I concluded that he should have been offered surgery. Mr B’s treatment fell significantly outside the suspected cancer pathway target time of 62 days from suspicion of cancer to treatment. Mr B had a biopsy done privately due to an unacceptable delay in the Health Board being able to undertake this procedure. Mr B should have had the opportunity to discuss his complex investigation results and treatment plan with a senior clinician. These complaints were upheld. Finally, I found failings in the initial complaint handling of this case. I recommended that the Health Board should: a) Apologise to Mr and Mrs B for the failings identified. b) Make a financial redress payment of £6,850

Ms D complained about the care and treatment her sister, Ms A, received from Wrexham Maelor Hospital (“the Hospital”) in July 2022 . Ms A had several medical conditions, including epilepsy (a condition which causes seizures), cerebral palsy (a condition that affects movement and co-ordination) and learning disabilities. She lived in a nursing home, had limited communication, and required 24 hour care and support. The Ombudsman found that the Health Board’s management of Ms A’s personal care needs, her nutrition and hydration, and communication with her fell below an adequate standard. On the occasions that the Learning Disability (“LD”) team and Ms A’s family were not present to assist, the nursing care on the ward fell short of acceptable standards, especially at weekends and overnight. No additional staff were brought in to support care delivery. There was no person-centred nursing care plan setting out the care objectives and adjustments that were needed to provide Ms A with effective care. This meant that staff did not fully understand her needs. The Ombudsman also found that there were multiple occasions when Ms A’s pain was identified by her family and the LD team, but it was unclear whether nursing staff were consistently able to identify pain, as the assessment tool used was not adapted for Ms A’s particular needs. This failure meant that Ms A suffered unnecessarily. The Ombudsman found that there was a poor standard of record keeping in relation to Ms A’s seizures. This was dangerous and represented a poor level of care. It was unclear whether nursing staff recognised Ms A’s seizures themselves, and had her family not been present, it is likely that many of her seizures would have gone unnoticed. Administration of medication was also found to be inadequate. Poor compliance with anti-seizure medication may have contributed to the increase in Ms A’s seizure activity. The Ombudsman made a number of recommendations, which the Health Board accepted. These includ

Mr C complained about the treatment he received from a Dental Practice within the Betsi Cadwaladr University Health Board area from November 2022 to May 2023. The Ombudsman investigated whether it was appropriate to refuse Mr C treatment due to him having dental work overseas, whether delaying Mr C’s filling by 6 months caused his tooth further damage, and whether it was appropriate to de-register Mr C from the Practice. The Ombudsman’s investigation found that the treatment Mr C received from the Practice was appropriate. Given the dental work Mr C had undergone abroad, we found that it was appropriate for the Dentist to refuse treatment. We also found that the delay in carrying out a filling did not cause the tooth further damage and that it was appropriate to de-register Mr C from the Practice when the relationship broke down. The Ombudsman did not uphold Mr C’s complaints.

Mr A complained that the Health Board’s complaint response contained inaccuracies in relation to his pituitary adenomas (non-cancerous tumours) and he provided clinical information in support of this. The Ombudsman was concerned about the continued inaccuracies, given that the Health Board had 2 opportunities to provide a complaint response. The Ombudsman identified that this had resulted in a loss of confidence by Mr A in the Health Board’s handling of his complaint. Under Early Resolution, the Health Board agreed to commission a report from an English NHS Hospital Trust (who were also involved in Mr A’s care) that would address Mr A’s specific points of concern including around his adenomas. On receipt of the commissioned report, the Health Board agreed it would share the report with Mr A and provide him with a further written apology in relation to the inaccuracies in its complaint response.

Mrs B complained that Betsi Cadwaladr University Health Board failed to provide a response to her complaint, about the care and treatment provided to her late husband, which she made to it in August 2023. The Ombudsman found that the Health Board had not provided regular and meaningful updates to Mrs B, and it had failed to issue a complaint response. She said this caused frustration and uncertainty to Mrs B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mrs B with an apology for the identified failures and to issue a complaint response within 20 working days.

Mrs L complained about the assessment, care and treatment given to her mother, Mrs M, by the Health Board when Mrs M presented at the Emergency Department following a fall on 21 July 2022. Ms L explained that, a month later, an X-ray found that Mrs M had a hip and pelvis fracture. The Ombudsman found that the documented assessment of Mrs M was not of an appropriate clinical standard. It overlooked her moderate pain score and did not explore the cause and location of her pain. There was no examination of Mrs M’s range of movement in her hips or her ability to weight bear. A more complete assessment might have identified tenderness, limited movement and/or immobility which, in turn, should have prompted an X-ray. The consequent uncertainty as a result of the missed opportunity to identify (or exclude) the presence of a fracture is an injustice. This is because we cannot know what more might have been done for Mrs M and what difference that might have made to her in the weeks following. The Health Board agreed to apologise to Mrs L for the shortcomings identified in the Doctor’s assessment, and the outstanding uncertainty about what an X-ray might have identified if it had been taken on 21 July. It also agreed to remind staff of the importance of documenting the site and type of pain when documenting a patient’s pain score, and of carrying out a full hip and pelvis examination in patients who are at high risk of fractures from falls. The Health Board agreed to complete these actions within 1 month.

Ms C complained about treatment provided by the Health Board. We investigated whether the decision, following an appointment in May 2021 with a consultant psychiatrist, that she was not entitled to treatment to address her binge eating (BED), was made appropriately and in line with relevant guidance. We considered whether, given the information available to the treating consultant psychiatrist by the August 2021 consultation with Ms C, she was then given sufficient treatment, including whether she should have been offered EMDR treatment from this date. Finally we investigated the Health Board’s handling of Ms C’s complaint, specifically that a complaint response of 5 October 2021 listed the report author as the person Ms C had made a complaint about, and that there were inaccuracies in some of the Health Board’s responses. We found that the Health Board did not offer appropriate support for people with BED, which contradicted relevant national guidance. While a lack of provision for eating disorders is a wider issue nationally, this was still an injustice to those within the area who needed this support, and particularly to Ms C, who was initially advised there could be a service to support her. We found that the Health Board had been provided with sufficient evidence that Ms C had been diagnosed with PTSD by the August consultation, and therefore efforts should have been made to source suitable treatment (which could have included EMDR or an appropriate alternative) from this date. We also found significant issues with the way Ms C’s several complaints were handled, as some of the findings appeared to have been based on incorrect information, and the complaint investigations were not always carried out in line with relevant guidance, which specifies that a staff member should not be involved in a complaint that relates to them. We therefore upheld these complaints. We recommended that the Health Board should apologise to Ms C for the issues we identified and offer

Mr X complained that the Health Board had failed to respond to his two complaints about a urological issue. The Ombudsman decided that there had been a failure by the Health Board to respond to the complaints and this had caused frustration and uncertainty for Mr X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Health Board to apologise to Mr X and provide him with a complaint response, which should also include an explanation for the failure and delay, within 2 weeks.

Ms X complained about the care and treatment her late mother, Mrs Y, received from Betsi Cadwaladr University Health Board (“the Health Board”). We investigated whether Mrs Y’s treatment from June 2022, when symptoms suggesting a recurrence of rectal cancer were identified, was appropriate and timely, including whether she should have been referred earlier to an oncologist. We also investigated whether Mrs Y was appropriately triaged and treated in the Emergency Department (“the ED”) on her admissions in August, including whether pain relief was appropriately supplied. We found that the investigations which Mrs Y underwent after June 2022 were appropriate, as was her referral to a specialist cancer hospital outside the Health Board’s area. However, the overall time before Mrs Y was seen by a consultant oncologist was too long and led to Mrs Y being unaware of her treatment plan for longer than she should have been. This was an injustice to her, and this part of the complaint was upheld. However, sadly, the outcome would not have been different if she had been seen by the consultant oncologist sooner, as her disease was already advanced by June. In relation to Mrs Y’s ED admittances, in terms of a specific concern Ms X had raised about a delay in replacing Mrs Y’s syringe driver on 1 admission, we found that although there was a short delay, Mrs Y was given intravenous morphine until it was set up, and this was appropriate. In terms of her admittances overall, we found that while Mrs Y was appropriately triaged on each of her admittances to the ED, this was not always as soon after her arrival as she should have been, and she was not seen within the time recommended for the triage category she had been allocated. While Mrs Y was offered pain relief each time, this was not always as promptly as she should have been owing to the wait for triage. In addition, the effectiveness of the pain relief was not checked. This complaint was therefore upheld. We recommended that t

Mr B’s family complained about the care provided to him by his GP practice and whether there was a failure to appropriately manage his Chronic Obstructive Pulmonary Disease (“COPD” – a long term lung condition) between March 2021 and August 2022. Specifically, whether Mr B’s medication was appropriately managed; whether referrals from other health professionals (including Pharmacists) were acted upon; whether appropriate reviews were undertaken; whether appropriate referrals were made, and; whether Mr B’s treatment plan was appropriate(including whether weight management should have formed part of the plan). The Ombudsman found that the care provided to Mr B by the Practice between March 2021 and August 2022 was acceptable and that his COPD was appropriately managed during this period. The Ombudsman did not uphold the first 4 complaints. The Ombudsman also found that Mr B’s treatment plan was acceptable overall. However, there was a missed opportunity for Mr B’s weight to be noted at the COPD therapy review on 23 June 2022 and, although there was no specific indication of detriment to Mr B or that the outcome would have been any different, this uncertainty was an injustice to Mr B. To that limited extent only, this element of the fifth complaint was upheld. The Ombudsman recommended that the Practice should write to Mr B’s family with an apology for the failing identified in the investigation. She also recommended that the Practice complete an audit of a random sample of COPD reviews conducted since 2023 to determine whether weight/BMI is being recorded and that appropriate dietician referrals or other action is taken, if indicated/required.

Mrs A had complained to the Health Board about the care provided to her young child by the Neurodevelopment Team at Wrexham Maelor Hospital. She had also raised concerns with the Health Board via her local MS. The Health Board treated Mrs A’s concerns as an enquiry and responded to those in a letter to the MS. The Ombudsman was of the view that the Health Board should have investigated and responded to Mrs A’s concerns under the PTR arrangements, instead of treating her concerns as an enquiry. That was maladministration and an injustice to Mrs A. The Ombudsman sought and gained the Health Board’s agreement to investigate and respond, in accordance with the PTR arrangements, to Mrs A’s concerns and to apologise for failing to do that in the first instance. It also agreed to offer Mrs A a payment of £250 to reflect the time and trouble she had been put to in pursuing this matter and for initially denying her an investigation and response under the PTR arrangements. The Health Board agreed to undertake these steps within 3 months.

Mr A complained about the lack of timely dental communication, updates and engagement by Betsi Cadwaladr University Health Board’s (“the Health Board’s”) orthodontic services in relation to his son, Child B. He questioned how the orthodontist services could have made decisions about his son’s dental care without seeing him. Child B had been referred back to the community for specialist dental review. As part of the settlement, the Health Board was asked to write to Mr A with an update on Child B’s referral and to provide information about the referral pathway. It was also asked to contact Child B’s dentist about the specialist dental referral and consider whether there was a need to improve communication with referring dental practitioners more widely about the referral pathway, if a communication gap was identified.

Mrs A complained about the care that she received from Betsi Cadwaladr University Health Board’s mental health services. Specifically, Mrs A complained that the Health Board failed to recognise and correctly diagnose her symptoms, and that there was an unreasonable delay in starting appropriate treatment. Mrs A also raised concerns about the contents of two conversations that she had with clinicians involved in her care. The Ombudsman concluded that the diagnoses made by the Health Board were reasonable ones to make at the time. Based on a consideration of the available evidence, the Ombudsman was also unable to conclude that the two conversations in question had been unreasonable. As a result, the Ombudsman did not uphold these aspects of Mrs A’s complaints. However, although the Ombudsman did not consider that there was any evidence of failings by the Health Board in terms of the events that led up to a decision to stop Mrs A’s sessions, the Ombudsman noted that there were shortcomings in how the decision to change psychologists was handled and that poor communication on the part of the Health Board contributed to the delay in Mrs A resuming therapy. Therefore, this aspect of the complaint was upheld to that extent. The Ombudsman recommended that, within 1 month, the Health Board should apologise to Mrs A for the shortcomings in communication that were identified in the investigation.

Mr A complained that Betsi Cadwaladr University Health Board failed to respond to the complaint he made to it in June 2023. The Ombudsman decided that there had been a significant delay by the Health Board to respond to Mr A’s concerns and this had caused inconvenience and frustration for Mr A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr A and pay him redress of £150 in recognition of the time and trouble he had spent complaining to the Ombudsman. The Health Board also agreed to provide Mr A with a complaint response within 4 weeks.

Mrs A complained about her mother, Mrs B’s management and care during her 8 months inpatient admission at Ysbyty Glan Clwyd (the First Hospital) and Holywell Community Hospital (the Second Hospital). She said that they had failed to try and find out what was wrong with her mother and had just watched her deteriorate. Mrs A referred to her mother’s weight loss, numerous blood transfusions and the fact she had become completely immobile. Mrs A also said that her mother’s osteomyelitis (an infection in the bone), which had been a pin prick wound prior to her admission, had worsened and never healed. As a result of her deterioration, her mother was not fit enough to undergo an investigation for her possible bowel cancer. Mrs A felt that the Health Board’s complaint response had been “highly selective” for example, it had not addressed her mother’s weight loss at the First Hospital. The Ombudsman noted that there had been dietetics’ involvement in Mrs B’s weight management and nutrition and on the face of it the actions taken at the Second Hospital appeared reasonable. As the Health Board did not address Mrs B’s weight management at the First Hospital it was not possible to say what regard had been given to this. Although Mrs B’s wound management during her inpatient care appeared to be appropriate, it was not clear from the Health Board’s complaint response what had happened in terms of a surgical review recommended by the tissue viability nurse (“TVN”) while Mrs B was an inpatient at the First Hospital. Additionally, the response did not sufficiently address Mrs A’s concern about her mother’s suspected bowel cancer symptoms while at the First Hospital. The Health Board agreed to provide a further response to Mrs A. The response would address Mrs B’s weight management, surgical review outcome as well as Mrs A’s concerns about her mother’s suspected bowel cancer symptoms while at the First Hospital.

Miss A complained that Betsi Cadwaladr University Health Board had failed to provide an independent review into her gynaecological care and failed to respond to her concerns in a timely manner. The Ombudsman found a review into Miss A’s gynaecological care was still not complete despite it being announced in May 2023. Miss A had also been required to approach the Ombudsman more than once to resolve her complaint. The Ombudsman decided to settle the complaint without an investigation. She sought and gained the Health Board’s agreement to complete the independent review into Miss A’s genealogical care and to offer a financial redress of £250 for the time and trouble taken to resolve her complaint. The Health Board agreed to complete these actions within 30 working days.

Mr A complained that Betsi Cadwaladr University Health Board failed to provide a response to his complaint, which he made to it in January 2024. The Ombudsman found that whilst the Health Board had acknowledged Mr A’s complaint, it had not provided regular and meaningful updates and a complaint response had not been issued. She said that this caused frustration and uncertainty to Mr A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mr A, within 2 weeks, with an apology for the lack of regular and meaningful updates and for the delay in issuing a complaint response. The Health Board also agreed to issue a complaint response within 8 weeks.

Ms A was concerned about the care provided to her late father by Betsi Cadwaladr University Health Board and GP Practices in the Health Board’s area. Ms A complained that when the Health Board responded to her complaint it failed to enclose the letters from the GP Practices (which the Health Board’s complaint response letter had said were enclosed). Ms A was also aggrieved that she was not provided with a copy of the Medical Examiner’s summary. The Ombudsman was concerned that the Health Board had not enclosed the letters from the GP Practices with its letter to Ms A. She decided to resolve the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms A for failing to enclose those letters with its complaint response and to provide those letters to Ms A. The Health Board agreed to undertake these steps within 1 month. With respect to the Medical Examiner’s summary, the Ombudsman provided Ms A with information about how to obtain that document.

Mr C has complained about the care his late mother-in-law, Mrs B, received from Betsi Cadwaladr University Health Board when she was admitted to Ysbyty Gwynedd in October 2021. Specifically, Mr C complained that Mrs B did not receive a reasonable standard of care, with a lack of communication with her primary carer to understand her care needs, which resulted in avoidable damage to her skin integrity. Mr C also complained that the complaint response he received from the Health Board was unnecessarily delayed which added to the distress and frustration suffered by the family. The investigation found that the Health Board provided a reasonable standard of care to Mrs B during her admission to Ysbyty Gwynedd in October 2021. This complaint was not upheld. However, the investigation also found that there were failings in the handling of Mr C’s complaint and this was upheld. The Health Board agreed to apologise to Mr C for the failings identified and review its complaint handling of this case to identify any lessons to be learned.

Mr X complained about the lack of any contact or support from Conwy CMHT between June 2022 and February 2023 despite having a care and treatment plan in place. The Health Board accepted that, during this period there was no contact from the CMHT, and there were no care records relating to Mr X between September 2021 and February 2023. In its complaint response, the Health Board apologised to Mr X for the failing and outlined the action that it had taken to prevent a recurrence. This included an audit of all open patient notes to check that there were no other documentation gaps. It further explained to the Ombudsman that it had introduced safeguards in its system, including an electronic spreadsheet to document the last contact with patients, so that any overdue contact with patients would be highlighted. The Ombudsman was concerned that the CMHT’s processes may not be robust to ensure that patients were not overlooked. The Health Board therefore agreed (within 2 months) to: • Review the CMHT’s system for identifying when a care and treatment plan review is overdue. • Audit and review the improvements it had made to the CMHT processes following the complaint to ensure that its current system was robust. The Health Board also agreed to provide an additional complaint response to Mr X covering the issue of qualifying liability in line with the regulations.

Mrs D complained that Betsi Cadwaladr University Health Board failed to provide a response to her complaint about the care and treatment provided to her father which she made to it in August 2023. The Ombudsman found that the Health Board had failed to issue a complaint response and had not provided regular and meaningful updates. She said that this caused frustration and uncertainty for Mrs D. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide an apology to Mrs D for the identified failings and to pay Mrs D £50 redress in recognition of her time and trouble in making her complaint to the Ombudsman within 2 weeks. It was further agreed that the Health Board would provide Mrs D with monthly updates on the progress of her complaint and issue a complaint response within 12 weeks.

Mrs A complained to Betsi Cadwaladr University Health Board (“the Health Board”) about the standard of care and treatment provided to her husband Mr A, whilst he was an inpatient in hospital. The Ombudsman found that the Health Board had failed to respond to Mrs A’s concerns that during Mr A’s hospital stay he had a very severe episode of chest pain and that he had rung his alarm several times but had no response from staff. The complaint specified that as a result, Mr A was forced to call Mrs A at home who then contacted the nurse’s station. Further, that Mr A may have suffered a possible Myocardial Infarction. The Ombudsman sought and gained the Health Board’s agreement to, within 28 days, provide a full response to Mrs A about her all concerns raised and provide an apology to Mrs A for failing to respond to all concerns in the original response.

Mrs C complained about the standard of care provided to her stepfather, Mr A, at Ysbyty Glan Clwyd and Llandudno General Hospital. Specifically she complained that Mr A was not given prescribed antibiotic medication on 15 April and should not have been discharged from hospital on 19 April. She also complained about inadequate equipment on discharge, and lack of physiotherapy input when Mr A was finally discharged home. Based on medical advice following review of the clinical records, the investigation concluded that there was no indication that Mr A was suffering from a UTI which required antibiotic treatment on 15 April, in line with NICE guidance. Therefore, whilst there was an administrative failing which meant that Mr A’s medical records were not transferred with him after 15 April, and so the antibiotic medication was not administered, this did not result in any detriment to him. Mr A should have been formally reviewed by a doctor prior to his discharge on 19 April and it was a failing that he was not. However, as stated above, as there was no indication that he was suffering from a UTI and required antibiotic treatment, Mr A’s discharge was clinically reasonable. The occupational therapy assessments completed prior to discharge, and the equipment provided, were reasonable. The investigation noted that, whilst Mr A was not referred for community physiotherapy when he was discharged home in May, he received ongoing occupational therapy care after his discharge and had relevant physiotherapy exercises to progress his functioning at home. The investigation did not uphold the complaints.

Ms C complained about the care and treatment her mother, Mrs A, received from the Health Board. Specifically, Ms C complained that Mrs A was unwell after her initial surgery on 4 June 2021 and was not fit to be discharged from Glan Clwyd Hospital. She also complained that Mrs A’s condition was not monitored adequately following her re-admittance to the Hospital on 5 June, prior to her second surgery on 8 June, and that communication with Mrs A’s family was poor throughout her admittance. Finally, Ms C was unhappy with the discharge planning on 24 June and follow-up care. The investigation found that Mrs A’s assessment for her first discharge on 4 June did not reach a reasonable standard and that the information provided was confusing. Furthermore, although the discharge process on 24 June was broadly appropriate, the investigation found that follow-up tests were not arranged and no outpatient appointments were scheduled. The Ombudsman therefore upheld these points. However, the investigation found that Mrs A’s condition was monitored adequately following her second admission on 5 June. In regard to communication, provision of information to Mrs A’s family could have been better between Mrs A’s second admission and her surgery on 8 June. However, the Health Board had already introduced guidance since Mrs A’s experience that addressed this matter. The Ombudsman did not uphold these points. The Ombudsman recommended that the Health Board should apologise to Mrs A and Ms C and ensure Mrs A receives the follow-up CT scan she needed. In addition, the Health Board should send nursing staff a copy of the Health Board’s Communication Guidance and share the relevant parts of this report with the staff involved in Mrs A’s nursing care at the time of her discharge on 4 June. Finally, it should review its discharge policies for inpatients having complex emergency abdominal surgery.