PSOW Individual Decisions

Mr A complained that Betsi Cadwaladr University Health Board failed to address his concerns in its response. The Ombudsman found that the Health Board had failed to respond to the questions raised by Mr A. She said this caused uncertainty 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, within 4 weeks, issue a further response and offer an apology for failing to address Mr A’s concerns.

Ms L complained that the Health Board failed to take timely and appropriate action to investigate her persistent diarrhoea and rectal bleeding in 2021, and then to identify and diagnose her colon cancer following her GP’s urgent referral in February 2023. The investigation found that, whilst a colonoscopy in 2021 did not identify any disease in Ms L’s bowel, there is a recognised “miss rate” which means that disease can be missed through no fault of the procedure or the clinician conducting it. Ms L’s cancer had probably developed from a polyp that was missed in the original 2021 colonoscopy. There were failures to consider this possibility and repeat that procedure, as well as a lack of appropriate proactive investigation to find the cause of Ms L’s ongoing symptoms. There were also lengthy delays confirming test results and arranging follow-up appointments. These failings and delays meant that the opportunity to remove this polyp, and therefore either prevent Ms L’s cancer from developing or identify it when it was easier to treat, was lost. Ms L’s treatment included 2 life changing surgeries, chemotherapy and radiotherapy, and the whole situation had a serious impact on her physically, mentally and financially. This was a significant injustice to Ms L. Accordingly, the complaint was upheld. The Health Board agreed to apologise to Ms L for the failings identified and offered her £4,000 in recognition of the serious consequences. It also agreed to remind relevant clinicians of the recognised “miss rate” in colonoscopies and the importance of fully investigating ongoing symptoms even if a colonoscopy is clear. The Health Board also agreed to review the waiting list for surveillance colonoscopies to identify any patients waiting with an urgent clinical need and to offer them an appointment. Finally, it agreed to confirm that the relevant doctor in this case reflected on the findings of the Ombudsman’s report at his next annual appraisal.

Mr C complained that Betsi Cadwaladr University Health Board had failed to progress a referral to the Posture and Mobility Service, to assist him while he was waiting for knee replacement surgery. The Ombudsman decided that the communication from Mr C’s doctor had been contradictory and that Mr C had been led to believe a referral had been made, when it had not. When the Health Board investigated Mr C’s complaint, it did not contact the doctor and relied solely on the limited information held by the Posture and Mobility Service. There was a missed opportunity to clarify and resolve the issues when the Health Board declined a request for a meeting to discuss Mr C’s concerns. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to send a referral form to Mr C’s GP for completion within 4 weeks. The Health Board also agreed to apologise for not investigating Mr C’s complaints sufficiently thoroughly, provide feedback to the doctor and prioritise consideration of the referral, when it was received.

Mr A complained that the GP Practice failed to provide appropriate care prior to his removal from its patient list. The Ombudsman found that, while the GP Practice had addressed Mr A’s concerns about being removed from the patient list, it had not provided a full written response regarding concerns he had raised about his care. This caused frustration and uncertainty for Mr A. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained agreement from the GP Practice to provide a comprehensive written response to Mr A’s concerns by 20 April 2026.

Mrs A’s complaint centred on whether the GP Practice failed to recognise her signs of heart failure and carry out appropriate investigations and a timely referral because it misdiagnosed her shortness of breath as asthma for 9 months between February and October 2024. The Ombudsman did not uphold Mrs A’s complaint. The investigation found that Mrs A’s asthma management was appropriate and that there was no objective clinical evidence to suggest that she had heart failure before October 2024.

Ms E complained about the standard of care provided to her adult daughter, Ms F, by one of the Health Board’s community mental health teams (“the CMHT”). The Ombudsman’s investigation considered whether: a) Whether the psychology approach in undertaking exposure therapy was appropriate. b) Whether the decision not to arrange an assessment for ADHD/ASD was appropriate. c) Whether the decision to discharge Ms F from the CMHT was appropriate. The Ombudsman found that the psychological therapy approach was in line with appropriate clinical practice and guidelines, based on Ms F’s presenting symptoms. This aspect of the complaint was not upheld. However, the Ombudsman was satisfied that there was evidence that a referral for an ASD assessment should have been made by the CMHT, and this aspect of the complaint was upheld. In relation to the decision to discharge Ms F from the CMHT services, this was not a clinically unreasonable decision. However, there were some shortcomings in how it was reached. Specifically, there was a lack of consultation with Ms F and an absence of clear information about the referral pathway for ASD assessment. This aspect of the complaint was partly upheld to that extent. The Health Board agreed to the Ombudsman’s recommendations which included an apology to Ms F for failing to refer her for an ASD assessment and to make that referral if Ms F still wished this. It also agreed to review its ASD/ADHD policies and referral pathways to ensure that they identify, and have clear pathways to refer, cases for ADHD/ASD assessment in line with NICE guidance (CG142) and the Quality Standard.

Mrs A complained about the neurology care she received from Betsi Cadwaladr University Health Board. This included care provided by an NHS Trust in England on behalf of the Health Board. The investigation considered the following: a) whether the Health Board adequately assessed and treated the cause of Mrs A’s tremor, taking into account potential interactions with prescribed medications b) whether Mrs A was inappropriately advised that she had an incurable condition that would prevent her from continuing to practice dentistry. The investigation found that there was no evidence that the possibility that Mrs A’s tremor had been made worse by a prescribed medication was considered or discussed with her. This should have been discussed with her even other if causes were considered much more likely. The Ombudsman upheld this complaint. The investigation found that the advice given about Mrs A’s ability to work was reasonable. Accordingly, the Ombudsman did not uphold this complaint. The Ombudsman recommended that the Health Board apologise to Mrs A and make a financial redress payment to her of £1,750. This included £750 in respect of the avoidable inconvenience and distress of living with the tremor for an additional 15 months. It also included £1,000 to reflect the potentially very significant impact of the loss of the opportunity for a different outcome to discussions about Mrs A’s early retirement. The Ombudsman also recommended that the Health Board should remind the clinicians involved in Mrs A’s care of the importance of discussing potentially relevant medication interactions with patients at the earliest possible opportunity and clearly documenting the consideration of medication interactions in patient notes.

Mr O complained on behalf of his wife, Mrs O, about care provided to her by Betsi Cadwaladr University Health Board (“the Health Board”). The investigation considered whether the Health Board failed to provide appropriate dressings for a wound to Mrs O’s left buttock between February and August 2024 and whether it failed to provide adequate assistance for Mrs O to safely access the taxi rank after she left Ysbyty Gwynedd Emergency Department (“the ED”) on 27 June 2024. The investigation found that on 16 March Mrs O had requested continuation of the previous wound care regime established before she moved to the Health Board’s area, but the Health Board’s clinicians recommended a change of approach without providing an adequate rationale. It was not until 17 July that district nurses recognised that the previous regime was more appropriate for Mrs O’s needs. The investigation found that the available evidence did not support that sufficient dressings were provided by the Health Board to meet Mrs O’s wound care needs prior to 17 July. While the types of dressings recommended by the Health Board’s clinicians were not inappropriate generally, there was a failure to recognise that they were not suitable for Mrs O, taking into account that her method of mobilising and patterns of activity caused her to need frequent daily dressing changes. The investigation found that, had the Health Board appropriately considered and addressed Mrs O’s needs sooner, the need for Mr and Mrs O to purchase dressings privately could have been avoided or at least reduced. This was an injustice to them. Accordingly, this part of the complaint was upheld. The Ombudsman made a number of recommendations including, an apology and a financial redress payment of £1000 to Mr and Mrs O for injustices caused by these failings. She also recommended service improvement actions, including a reminder of expected care standards for relevant clinicians and a review of procedures for managing patients who move

Mr B complained about the inpatient care and treatment his late father, Mr A, received at Ysbyty Glan Clwyd in 2024. The investigation focused on whether it was appropriate to stop Mr A’s long-term oxygen therapy (“LTOT” – supplemental oxygen usually given via a nasal tube from a portable machine) given the fact that he was on it at home. The investigation also considered whether there was a delay in escalating Mr A’s care on 11 February and whether a higher National Early Warning Score (“NEWS,” a clinical tool used to determine whether a patient’s care needs to be escalated) would have changed his management. The investigation found that even though Mr A was on LTOT, providing supplementary oxygen for 15 hours and not 24 hours was appropriate. The investigation concluded that stopping Mr A’s LTOT was reasonable, appropriate and in accordance with accepted clinical guidance. Accordingly, this aspect of Mr B’s complaint was not upheld. Mr A’s records showed that his NEWS was fairly stable throughout 11 February, and that there were no delays in escalating Mr A’s care as his condition was relatively stable. Whilst not part of the investigation remit, the investigation did identify a delay in reviewing Mr A on 10 February; based on his recorded NEWS this should have prompted an urgent medical review. However, as Mr A responded to the increased supplemental oxygen and his NEWS improved promptly, the fact that a medical review did not take place was, on balance, not unreasonable and therefore did not cause him an injustice. This part of Mr B’s complaint was also not upheld.

Mrs C complained about the care and treatment she received from a Dental Practice in the area of Betsi Cadwaladr University Health Board. Mrs C complained that the Practice did not perform dental work to an appropriate standard when it carried out 2 fillings on 27 February and 2 extractions on 20 March 2025. She also complained that the Practice did not provide appropriate aftercare following the extractions of 20 March. The investigation found that the dental work carried out by the Practice on 27 February and 20 March reached an appropriate standard, so this point of Mrs C’s complaint was not upheld. However, it found that, although the Dentist’s own aftercare was appropriate following the extractions of 20 March, there was a lapse in the Practice’s internal communication. The second point of Mrs C’s complaint was therefore upheld. The Ombudsman recommended that the Practice apologise to Mrs C for this lapse, and remind reception staff of its process regarding notifying dentists of contact from patients. The Practice agreed to implement the Ombudsman’s recommendations.

Mr B complained about the treatment he received from Betsi Cadwaladr University Health Board (“the Health Board”), specifically whether a prescription of methadone (used in the treatment of opioid addiction) was managed appropriately and in keeping with relevant guidance and whether a decision not to prescribe anti depressant medication was appropriate and in keeping with relevant guidance. The Ombudsman found that the prescription of methadone was managed appropriately and consistent with relevant prescribing guidance and clinical standards. This part of Mr B’s complaint was not upheld. The decision not to prescribe Mr B anti depressant medication was also appropriate, in keeping with relevant guidance and took in to account the situation in the prison at the time. This part of Mr B’s complaint was not upheld.

Mr C complained about the care and treatment he received between September 2023 and July 2024 following his prostate cancer diagnosis. In particular, we considered the significance of the delays in Mr C receiving a prostate-specific membrane antigen positron emission tomography scan (“PSMA PET scan” – an advanced imaging test that uses a radioactive tracer to identify and visualise prostate cancer cells). We also considered the delay in Mr C receiving hormonal therapy, and the impact this had on the spread of the cancer. The investigation found that whilst the care and treatment Mr C received, overall, followed the NHS Wales National Optimal Pathway (“NOP”) for Prostate Cancer, there were significant delays in Mr C’s journey on the NOP which led to him waiting more than 3 times as long as he should have done before his treatment was started. A biopsy in January 2024 indicated that a PSMA PET scan was appropriate for Mr C, but it did not happen for almost 4 months. This delay was unacceptable and amounted to service failure. The delays in Mr C’s pathway more likely than not contributed to his cancer being more advanced. This uncertainty will sadly be an enduring injustice for Mr C and his family, so this part of his complaint was upheld. In relation to Mr C receiving hormonal therapy sooner, the investigation found that it was appropriate for Mr C not to have started this therapy before the outcome of the PSMA PET scan was known as this would have had a potentially significant impact on the interpretation of the PSMA PET scan itself. However, as there had been a significant and unnecessary delay in Mr C undergoing the PSMA PET scan, it followed that there was also a subsequent delay in his hormonal therapy commencing. This was also an injustice to Mr C and this part of his complaint was also upheld. Of further concern was the Health Board’s failure to recognise the delays highlighted when it responded to Mr C’s complaint. In the thematic report “Groundhog Day 2”, thi

The Ombudsman investigated Mr C’s complaint about whether his grandfather, Mr A, was appropriately managed and treated when he was admitted to Ysbyty Glan Clwyd between 11 and 20 December 2024. In particular, it considered whether Mr A’s nutritional needs had been met during this period. The investigation also looked at Mr C’s complaint handling concerns. The Ombudsman’s investigation found that broadly Mr A was appropriately managed and his nutritional needs were adequately met. However, the investigation identified that neurological observations that Mr A underwent following an unwitnessed fall on 13 December were inadequate. Despite this there did not appear to have been any adverse effect on Mr A, and the observations were in accordance with Betsi Cadwaladr University Health Board’s (“the Health Board’s”) policy. The investigation found that information about a further fall that Mr A sustained while in the Emergency Department was not communicated to Mr A’s family or recorded in his medical or nursing records. The Ombudsman’s investigation concluded that record keeping fell short of the professional standards expected. It was to this limited extent only that Mr C’s complaint was upheld. The Ombudsman found that the Health Board’s complaint response was not as complete as it could have been, as the communication and documentation shortcomings relating to Mr A’s second fall were not addressed. The Ombudsman’s investigation concluded that the administrative shortcomings around complaint handling meant that opportunities were missed for the Health Board to learn lessons, it also caused Mr C an injustice as he had to complain further in order to get answers. This aspect of Mr C’s complaint was upheld. The Ombudsman’s recommendations included the Health Board apologising to Mr C; and in order to facilitate learning, sharing the report with staff involved in Mr A’s care and the Health Board considering whether to update its falls policy to provide additional clarity ar

Ms C complained about the actions of the Health Board in determining whether her father, Mr D, was eligible for NHS Continuing Health Care (“CHC”) funding. Mr D had significant and specific care needs due to early onset dementia. The Ombudsman investigated whether: a) the process followed by the Health Board to assess Mr D’s eligibility for CHC funding was in line with the National Framework b) the Health Board appropriately addressed the issue of Mr D’s CHC funding eligibility in its response to the complaint. c) the Health Board’s response to the complaint was timely and reasonable. The Ombudsman’s investigation found that the Health Board had not followed the process to determine Mr D’s CHC eligibility in line with the National Framework. This constituted maladministration. Following complaints from Mr D’s MS and Ms C, the remedial action taken by Health Board was inadequate. Its reasoning for the current funding position was unclear, and it had not properly addressed the potential financial implications for Mr D of the maladministration going back to the point he was discharged from hospital. The Ombudsman upheld all 3 parts of the complaint. The Ombudsman made a number of recommendations, which were accepted by the Health Board. These included: • an apology to Ms C • ensuring that it had now reached a CHC eligibility decision in line with the Framework • undertaking a retrospective review of Mr D’s CHC eligibility for the whole period dating back to his discharge from hospital • reviewing its dispute resolution process (with the Council) • arranging a joint review (with the Council) to identify improvements arising from the shortcomings identified in this case.

Mrs A complained that Betsi Cadwaladr University Health Board failed to provide sterile and hygienic catheter care, and support her in her catheterisation regime, whilst she was inpatient. Mrs A believes that this resulted in her contracting an infection. The Ombudsman identified that it was documented that Mrs A was to have hourly catheter flushes, however, there was a lack of documentation to support the clinical decision making. The Ombudsman sought and gained the Health Board’s agreement to within 4 weeks, provide Mrs A with a further response on the issue identified and if possible, provide an explanation on why hourly flushing was indicated. Further, to reconsider and respond to Mrs A’s concern that the care and treatment provided contributed to the infection, in light of the issue identified.

Mr A complained that Betsi Cadwaladr University Health Board had not fully addressed his complaint about the care provided to his late mother. The Ombudsman found that the Health Board’s complaint response had not adequately addressed the concerns Mr A had raised in his complaint. This amounted to maladministration which caused Mr A an injustice. Instead of investigating the complaint, the Ombudsman obtained the Health Board’s agreement to apologise to Mr A for failing to adequately address his concerns and to issue a further complaint response which sought to remedy this. The Health Board agreed to undertake these steps within30 working days.

Mrs A complained about the care and treatment provided to her late husband by Betsi Cadwaladr University Health Board. Mrs A was dissatisfied with the Health Board’s response to her complaint. The Ombudsman found that, although the Health Board had investigated Mrs A’s concerns, the complaint response had not adequately addressed matters for her. Mrs A was inconvenienced by the Health Board’s actions and this has caused frustration for her. The Ombudsman decided to settle the complaint without an investigation. The Health Board agreed to, within 4 weeks, contact Mrs A to arrange a meeting, between Mrs A and relevant staff, to discuss the outstanding concerns and to provide a further complaint response within 16 weeks

Ms C complained about the care and treatment provided to her late mother, Mrs B, by the Health Board following hip replacement surgery in December 2023. The investigation considered whether it was clinically appropriate for Mrs B to have a general anaesthetic for her surgery, and whether it was clinically appropriate for Mrs B to have been discharged from hospital following her surgery on 4 January 2024. It also considered whether it was clinically appropriate for Mrs B to have been subsequently discharged from the Emergency Department (“ED”) on 13 February 2024 and 20 February 2024. The Ombudsman found that the choice of general anaesthetic for Mrs B’s hip surgery was appropriate and in line with accepted good clinical practice. Furthermore, given Mrs B’s condition, it was reasonable to have discharged her on 4 January 2024. Those complaints were not upheld. However, Mrs B was discharged from the ED on 13 February without pneumonia being reasonably explored and diagnosed, and she was therefore discharged without appropriate treatment at that time. That was a service failure and an injustice to her. The Ombudsman upheld this aspect of the complaint. When Mrs B was re-admitted on 19 February with the same symptoms, it was recognised that she had pneumonia, appropriate treatment commenced and her discharge from the ED on 20 February was reasonable. The Ombudsman did not uphold that part of the complaint. The Health Board agreed to the Ombudsman’s recommendations to provide Ms C with an apology for the failings identified; to review this case in relation to the clinical investigations carried out for Mrs B between 10-13 February 2024 to identify any points of learning which can be applied in future care, and to ensure, as part of a reflective process, that the General Medical Consultant responsible for discharge on 13 February shares details of this case and the Ombudsman’s report at their annual appraisal.

Mr B complained about the care and treatment he received from the Health Board for prostate cancer. Specifically, whether his clinical management and communication between July 2024, when he was referred to hospital, and 3 February 2025 when chemotherapy treatment commenced, was appropriate, timely and in keeping with relevant guidance. The Ombudsman found that Mr B’s clinical management and the way the Health Board communicated with him was not appropriate. There were avoidable delays in Mr B’s treatment which was not in keeping with relevant guidance. Mr B was also not provided with some relevant information, which meant he was unable to make informed decisions about his care. Mr B’s complaint was upheld. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr B for these failings. The Health Board also agreed to share the investigation report with the clinicians involved in Mr B’s care so that the findings could be considered and discussed and to review the way it collects and shares information on estimated waiting times for oncology referrals.

Mr B complained that the Health Board failed to diagnose his father, Mr A’s, bladder cancer in a timely manner following referral from his GP on 19 July 2023. The investigation found delays in the diagnosis and treatment of Mr A’s bladder cancer and that failures occurred. However, it also found that it was unlikely Mr A’s sad outcome would have differed if care and treatment had been more timely, due to the aggressive nature of his cancer. Nevertheless, it found that Mr A suffered an injustice as he lost the chance to receive certainty about his condition and be provided with palliative care sooner. This complaint was therefore upheld. The Health Board agreed to carry out the Ombudsman’s recommendations to apologise to Mr B, and to introduce a tracker of referrals of patients with suspected cancer to ensure delays are visible. It also agreed to conduct an audit of all patients who are under suspicion of malignancy and are awaiting 2 combined procedures or more to assess whether both procedures are necessary to diagnose malignancy. If not, the necessary diagnostic procedure should be arranged and undertaken in isolation if this would ensure a timelier investigation for diagnosis of malignancy.

Mr A complained about the orthopaedic management and care he received at Betsi Cadwaladr University Health Board’s Ysbyty Glan Clwyd. Specifically, Mr A’s complaint centred on the appropriateness of the decision to refer him for specialist intervention in 2023 for a non-healing fractured femur (thigh bone) and for him to limit weight-bearing on that leg. Mr A was concerned that this delayed physiotherapy input and his recovery. The Ombudsman’s investigation concluded that it was clinically appropriate for Mr A to be partially weight-bearing (“PWB”) on that leg between August and October 2023, given there were areas where Mr A’s femur was not healing. However, the Ombudsman identified that an updated X-ray should have been carried out before the decision to make a specialist referral and for Mr A to continue PWB was made in the December. Had this happened, X-rays might have shown that Mr A’s femur was healing and therefore prompted a change in his PWB status. The investigation identified that during the significant time (December 2023 to May 2024) that Mr A remained PWB, there were inadequacies both in monitoring and progressing the specialist referral and in follow-up clinic reviews. Mr A will have to live with the uncertainty of not knowing whether the degree of physiotherapy input that would have assisted his recovery could have happened sooner. This is an injustice to him. It was to this extent that Mr A’s complaint was upheld. The Health Board agreed to carry out a number of recommendations. These centred on apologising to Mr A, clinician learning through the sharing of this report, and in terms of onward specialist referrals, that it review and evidence to this office that there are effective mechanisms in place for clinicians to monitor and to check progress on these referrals, or provide an action plan setting out how this will be achieved.

Mrs A complained that Betsi Cadwaladr University Health Board failed to address the concerns she raised regarding the hysterectomy. The Ombudsman found that, while the Health Board had been in discussion with Mrs A regarding her concerns, it had failed to provide her with a formal complaint response. The Ombudsman said this caused uncertainty and frustration for Mrs A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, issue the complaint response and provide an apology and explanation for not addressing the concerns via the Putting Things Right complaint procedure.

Mr C complained about the care that Betsi Cadwaladr University Health Board provided to his grandmother, Mrs X. He disputed some of the information in the Health Board’s response and complained that there was insufficient evidence of learning. The Ombudsman decided that the Health Board’s complaint response had not adequately addressed the concerns raised by Mr C. The response did not fully reflect the information in Mrs X’s clinical records. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mr C within two months to address the concerns and describe any further action to be taken.

Mr A complained that staff at Betsi Cadwaladr University Health Board (“the Health Board”) had harassed him and scheduled appointments without his consent. The Ombudsman found that although the Health Board had responded to Mr A’s complaint it had not provided a satisfactory response and had not responded to subsequent complaints. The Ombudsman decided to settle the complaint without an investigation on the basis that within 1 month of issuing the decision letter the Health Board would: Write to Mr A and provide a detailed complaint response to his initial and all subsequent complaints.

Mrs A complained that there was a failure by the GP Practice to refer her brother to secondary care in a timely manner between March and May 2024. As a result, there was a delay in identifying that his previously diagnosed bowel cancer had spread to his right parotid gland (a salivary gland just beneath and in front of the ear). The investigation found that the GP Practice’s management and care was reasonable and appropriate. Based on her brother’s presenting symptoms, there was no reason to suppose that they were anything other than an ear infection/congestion. Mrs A’s complaint was not upheld.