Betsi Cadwaladr: Ombudsman raises concerns after north Wales health board receives most complaints

• ITV Wales' Joanne Gallacher reports from Denbigh.

Wales' Public Service Ombudsman (PSO) has raised concerns after revealing that Betsi Cadwaladr University Health Board (BCUHB) has been the most complained about in Wales over the last two years.

Since the start of 2024, more than half of the Ombudsman's public interest reports, which are produced about the most serious complaints, have been about the north Wales health board.

The Ombudsman's latest annual report, dated 2023-24, shows Wales' biggest health board received 214 complaints. Other Welsh health boards received no more than 175 complaints in the same period.

BCUHB covers the whole of north Wales and serves around one in five people in the country.

It means it is not the most complained about health board per 1,000 residents (0.31). That unwanted accolade goes to Hwyel Dda University Health Board (0.36), followed closely by Swansea Bay University Health Board (0.34).

Despite this, Michelle Morris, Wales' PSO, singled out BCUHB for criticism. The health board has received the most complaints in both years Ms Morris has been in the job and has been the subject of the bulk of reports her office has published.

She exclusively told ITV Wales: "I've been in my role now just over two years...consistently Betsi Cadwaladr is the health board which has the highest number of complaints and those complaints have been referred on to us.

"Where we investigate something and we find a very serious issue, a serious injustice to a patient or perhaps something which is a systemic problem across the organisation, then I issue a public interest report and I've issued seven public interest reports relating to Betsi Cadwaladr and three of those this summer, so that's showing a concerning trend in the number of complaints that we are seeing.

"I know this was a concern for my predecessor as well so it is something that's been going on for a number of years, and we've got to remember behind every one of those complaints is a patient, a family who are looking for answers to something that's happened in their lives."

Chief executive of Betsi Cadwaladr University Health Board Carol Shillabeer said "tangible improvements" have been made, but added that "this is a long job and there are lots more improvements to be made".

Ms Shillabeer said some things "could've been avoided, some of them not". However, said they have changed the way they look and deal with complaints and will ensure families and patients are involved "much, much earlier in the process".

These areas included the timely escalation of patients with critical and high-risk conditions and strengthened oversight of the waiting area compared to previous inspections.

Peter Minshull's story

One woman looking for answers is Marilyn Minshull from Denbigh. The former teacher lost her husband Peter to cancer in 2020.

She says his was an "untimely death" and claims mistakes were made around his diagnosis. She has complained to Betsi Cadwaladr University Health Board about her husband's treatment at Ysbyty Glan Clwyd in Bodelwyddan but has never been told if lessons have been learned and changes implemented.

"Peter had a history, a family history of colorectal cancer, he'd been tested for an hereditary gene and he tested positive back in the 80s," she explained.

"He'd lost his father at a young age, two brothers had been affected from it and he himself had surgery - all of this at Ysbyty Glan Clwyd."

Despite this background to his case, Marilyn, who was married to Peter for nearly 50 years, said things went wrong.

"He had all the classic symptoms of something being wrong," she said.

Peter, a founder member of Denbigh Rugby Club, eventually had a CT scan and they were told it was "all clear".

However, after becoming more unwell and further tests being demanded and appointments chased, Peter and Marilyn were given the devastating news that cancer had been detected and an operation could no longer be offered.

Marilyn recalls: "The consultant said 'I'm sorry but it's more serious than we thought, I've re-checked the scan and there was a tumour there but it wasn't picked up'.

"It wasn't detected and a member of staff came up to us and said I'll give you the details of our complaints team because you need to put in a complaint.

"I keep saying this was an untimely death and how could it have been missed?"

Four years on from her husband's death, Marilyn is still searching for answers.

Ms Shillabeer said she could not talk about Peter's case but told ITV Wales she will contact Marilyn to offer to meet with her and discuss what progress the health board is making.

Following previous scrutiny, efforts have already been made across Betsi Cadwaladr University Health Board to improve its facilities and services.

Healthcare Inspectorate Wales (HIW) recently revealed it was de-escalating Ysbyty Glan Clwyd in Rhyl from its 'needs significant improvement' status, following an unannounced follow-up inspection of the emergency department.

In May 2022, the department was designated as a 'service requiring significant improvement'.

During the recent inspection over three consecutive days in April and May this year, HIW said it "found a marked improvement within the areas of significant concern identified in 2022".

These areas included the timely escalation of patients with critical and high-risk conditions and strengthened oversight of the waiting area compared to previous inspections.

Ms Shillabeer said she believes this is positive news and shows changes are being made.

The story of 'Mrs K'

The Ombudsman's concern came after she published a third public interest report regarding care given by Betsi Cadwaladr University Health Board in this summer alone.

In it, Michelle Morris said the death of a patient may have been prevented had appropriate treatment been given.

A new public interest report issued found that had Mrs K been treated appropriately at the outset by Betsi Cadwaladr University Health Board, her acute pancreatitis would have been treated successfully and on balance, her deterioration and death might have been prevented.

The Ombudsman launched an investigation after Mrs L complained about the care and treatment of her late mother, Mrs K, received from Betsi Cadwaladr University Health Board between January 2021 and her death on 31 January 2022 from biliary sepsis.

The Ombudsman concluded that if Mrs K had been treated appropriately at the outset, her pancreatitis would have been treated successfully and her deterioration and death may have been prevented.

There was little-to-no evidence that the seriousness of Mrs K’s condition was appropriately communicated in October to her and her family either before or after treatment.

The Ombudsman also found that the health board’s response to the complaint lacked candour and there had been a further lack of objective reflection during the Ombudsman’s investigation when the health board had sight of the Ombudsman’s clinical advice.

Commenting on the report, Michelle Morris said: “The failure to identify Mrs K’s gallstones in January 2021 was an unacceptable service failure which caused Mrs K and her family a continued and grave injustice.

"I am saddened to conclude that, had Mrs K been treated appropriately at the outset, her acute pancreatitis would have been treated successfully and on balance, her deterioration and death might have been prevented."

She added: "I am deeply concerned at the health board’s seeming lack of candour in its complaint response to Mrs L, and its lack of objective reflection by its clinicians during my investigation in that it continued to fail to identify and acknowledge failings in Mrs K’s care.

"I am mindful that the episode of care happened during a time when there were still some restrictions in place as a result of the Covid-19 pandemic.

"However, having taken full account of the potential impact of those restrictions, I have been that reassured that, even with the Covid-19 restrictions on endoscopy services, Mrs K would have accessed appropriate treatment within a few weeks.”

'We fell short of the standard that should be expected'

Carol Shillabeer acknowledged the failures to Mrs K's care.

She said: “On behalf of the health board I apologise unreservedly for the failures identified in Mrs K’s care, we fell short of the standard that should be expected. We are sending a direct letter of apology to Mrs L, and we wish to assure her that we addressing concerns raised, and that we are committed to improving our services.

“We take the Ombudsman's findings very seriously and acknowledge her comments surrounding our complaint handling and responses. The health board takes its duty of candour, the contract we have with the public to be open and honest, extremely seriously and we will continue to ensure we learn and address the concerns raised in Ombudsman's conclusion."

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