Ombudsman slams Betsi Cadwaladr care failings

A damning report by the Public Services Ombudsman for Wales has found serious failings in a woman’s care by Betsi Cadwaladr University Health Board and services it commissioned from English NHS Trusts, leading to lasting physical and psychological harm.

The investigation was prompted by a complaint from a woman, referred to as Ms A, concerning her treatment for complications related to inflammatory bowel disease.

The Ombudsman examined how her care was handled between 2019 and 2022 by both the Health Board and Liverpool University Hospitals NHS Foundation Trust.

Key failings included a lack of informed consent before major surgery, during which Ms A signed a consent form on the day of the procedure.

No previous record existed of any discussion about the possible removal of her uterus and ovaries.

The Ombudsman said this failure potentially engaged her Article 8 rights under the Human Rights Act, relating to bodily autonomy and private life.

The report also found that Ms A suffered from a persistent pelvic infection and pain for nearly three years before undergoing surgery.

Her condition worsened due to missed opportunities for treatment, inconsistent referrals, and poor coordination between colorectal and gynaecological teams.

Ms A described the experience as “horrific”, saying she felt like a “shadow” of her former self. She only discovered she had undergone a hysterectomy after waking from the operation and being told by a nurse.

“I’m avoiding people; people ask me about my health and I’ve lost my confidence,” she said. “I feel like a shadow of my former self.”

There was also criticism of the Health Board’s handling of her complaint and its contract monitoring processes.

While it held legal responsibility for the care arranged in England, its oversight focused on financial reporting rather than patient safety or service quality. As a result, serious shortcomings in Ms A’s care were missed.

Betsi Cadwaladr University Health Board has faced continued scrutiny in recent years.

In February 2023, the Welsh Government placed the Health Board under special measures—the most serious form of intervention—following a review by Audit Wales which raised significant concerns about its performance, leadership, and organisational culture.

Ombudsman Michelle Morris described the case as a “deeply troubling failure”.

Commenting on the report, she said: “I am mindful of the profound injustice caused to Ms A as a result of the significant failings that have occurred in her case.

“I am extremely concerned about the process by which Ms A gave her ‘consent’ for the surgery in March 2022. The relevant guidance makes it clear that consent is not simply a matter of completing and signing a form.”

“Instead, consent is a process which should begin well in advance of the day of the surgery, and any discussions should be clearly and separately recorded as part of the consenting process. This did not happen here.”

“This sad case also highlighted the wholly inadequate contract monitoring arrangements in place at the Health Board. Public bodies must have robust governance arrangements and must ensure that patient safety and the monitoring of the quality of services is in place.”

“The Health Board’s failure to monitor patient safety and service quality led to it missing crucial opportunities to address poor performance. With more effective contract monitoring, many of these failings could have been prevented.”

The Health Board has accepted a series of recommendations, including:

• Issuing a formal apology to Ms A.

• Requesting the Trust involved conduct a case review, remind clinicians of consent standards, and share the learning.

• Seeking written assurance that identified clinical failings are being addressed.

• Prioritising the rollout of a Commissioning Assurance Framework to better monitor the quality and safety of care.