Admissions/discharge and transfer procedures : Betsi Cadwaladr University Health Board

Mr A complained about his late wife, Mrs A’s cancer treatment and care at Betsi Cadwaladr University Health Board’s (the Health Board) Ysbyty Gwynedd and that the failure tore-schedule a follow-up appointment meant there was a 6 months’ delay in his wife starting cancer treatment following a CT scan in January 2019. Mr A also had concerns that the clinical/administrative processes to ensure the results of a CT scan were not overlooked were not sufficiently robust and in terms of complaint handling, not enough action had been taken to learn lessons from his wife’s case.

The Ombudsman’s investigation found that even if Mrs A had received prompt and timely treatment, given the way her tumour responded when treatment commenced, this would not have changed her outcome. He did not uphold this part of Mr A’s complaint.

The Ombudsman identified that the more robust clinical and administrative processes the Health Board had since identified could have been put in place to have prevented the sequence of events that led to Mrs A’s delayed cancer treatment. He considered that the failings caused Mrs A and the family considerable distress and was an injustice to them. In relation to complaint handling the Ombudsman’s investigation found administrative failings and concluded that the Health Board could have done more to ensure there was effective organisational learning from Mrs A’s complaint. Mr A’s loss of confidence in the Health Board’s complaints process, coupled with the added inconvenience of having to complain further to get the necessary assurances, was an injustice for Mr A. The Ombudsman upheld both these parts of Mr A’s complaint.

The Ombudsman recommended that the Health Board apologise for the failings identified, implement a Health Board-wide procedure for the booking of clinic appointments (if this was not already in place), and share the report with the Chair of the Health Board and its Patient Safety and Clinical Governance Group for them to consider whether any wider organisational learning can be gained from Mrs A’s case.