Clinical treatment in hospital : Betsi Cadwaladr University Health Board

Mrs D complained that there was a delay in the diagnosis and treatment of her late husband, Mr D, by Betsi Cadwaladr University Health Board and a GP Practice within the Health Board area. Mrs D complained that there were missed opportunities for the Health Board to diagnose Mr D with interstitial lung disease (“ILD” – an umbrella term which covers a number of different lung diseases) and idiopathic pulmonary fibrosis (“IPF” – a type of lung disease) between 2015 and 2021. Mrs D also complained that Mr D was referred to the Respiratory Clinic in January 2021 but was not seen until 28 May 2021. Mrs D complained that Mr D visited the Practice frequently in the years preceding his death and his ILD was not diagnosed on the occasions he presented with relevant symptoms. Mrs D also complained that the Practice should have taken action to expedite Mr D’s appointment with the Respiratory Clinic in 2021 when he presented with worsening symptoms.

The Ombudsman found that there were missed opportunities for the Health Board to diagnose Mr D with ILD and this complaint was upheld. The investigation found that the time taken for Mr D to be seen in the Respiratory clinic in 2021 was reasonable and this complaint was not upheld. The investigation also found that the care and treatment provided by the Practice was reasonable and these complaints were not upheld.

The Health Board agreed to apologise to Mrs D and make a payment to her of £2000 for the missed opportunities to diagnose Mr D, the uncertainty this caused him, and the ongoing uncertainty and distress this has caused Mrs D. The Health Board also agreed to share the report with relevant clinicians, ensure all relevant clinicians are reminded of their duty to take appropriate action when abnormalities are identified on images, and to provide an update on the actions identified in the Health Board’s own
investigation to ensure incidental radiological abnormalities are dealt with and for Radiology Governance to consider adding to report conclusions if appearances have progressed since previous images.