Clinical treatment in hospital: Betsi Cadwaladr University Health Board

Miss L complained about the care provided to her late mother, Mrs L, by Betsi Cadwaladr University Health Board (“the Health Board). Miss L questioned whether the insertion of renal stents was reasonable, if 2 discharges from hospital were appropriate, if the circumstances that led to Mrs L suffering a fall were avoidable and if Mrs L’s weight loss was appropriately managed.

The Ombudsman found that whilst it was appropriate to insert a stent on Mrs L’s right side some clinical records were missing, and it could not be determined if it was reasonable to insert a stent on her left side. The Ombudsman found that the failure to maintain records was a serious failing. In respect of the 2 discharges from hospital the Ombudsman found that they were unreasonable, and that medical records relating to the second discharge were missing. The Ombudsman found that at the time Mrs L fell in hospital she was wearing inappropriate footwear, and if appropriate measures had been taken to address this it was less likely she would have fallen. The Ombudsman found several shortcomings in the monitoring of Mrs L’s weight and food intake, and that if these had not occurred Mrs L might not have lost so much weight. As such all elements of the complaint were upheld.

The Health Board agreed to apologise for these failings and to offer Miss L a redress payment of £750. It was also agreed to remind staff of the need to follow appropriate guidelines and investigate the absence of some of Mrs L’s medical records, and identify action to prevent future occurrences and share the report with relevant staff.