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 around the management of unwitnessed falls as well as addressing the issue of communication with relatives about falls.