Rhyl woman’s dismay as Ombudsman declines to investigate mum's death

Margaret Anson died of sepsis at the Bodelwyddan hospital aged 73 on June 13, 2022.

But after her family raised concerns that she was incorrectly transferred to Denbigh Community Hospital on June 3, and that communication with her relatives was poor, the health board acknowledged these mistakes and apologised for them.

An internal investigation by the health board found that a “clear breach of duty” had been committed in Mrs Anson’s case.

Her daughter, Vanessa Jones, then reported the case to Ombudsman, but was told earlier in May that she was too late in filing her complaint.

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‘Kindest’ Rhyl woman who died at Glan Clwyd was victim of ‘clear breach of duty’

Margaret Anson (centre) with her family (Image: Vanessa Jones)

Ombudsman generally expects people to complain to us within 12 months of the issue or when they became aware of the issue, though it has some discretion to consider reports beyond this timeframe.

But Mrs Jones has asked Ombudsman to investigate it nonetheless, labelling its general one-year time limit “disgusting and ridiculous”.

She said: “The letter from Ombudsman pushed me over the edge. Betsi Cadwaladr admitted breaches in my mother’s case, so I don’t get it.

“I didn’t know of any time limits at the time, but I did it as soon as I could.

“Betsi could not have attempted to contact me, as the letter says, as they didn’t have my details, because I wasn’t down as my mum’s next of kin.

“If nobody takes responsibility for what happened, nobody’s ever going to learn from it. I don’t want the same mistakes to be made again.

“I was so happy when I thought something was going to be done, but this just broke my heart. My mother didn’t have to die, that’s the worst thing.

“No matter what, I can’t get past it. I want Ombudsman to reconsider it.”

Mrs Anson initially attended Glan Clwyd’s emergency department (ED) on the evening of April 27, 2022, suffering from a skin rash and blisters, before self-discharging the following day.

Margaret Anson (Image: Vanessa Jones)

She returned to the ED on May 1, and was admitted to an acute medical unit the day after, but self-discharging again on the same date.

On May 12, she attended the ED again after a fall at home, which caused her to suffer a deep cut to her leg.

Mrs Anson was transferred to a different ward on May 14; the initial impression being that she was suffering from sepsis.

She then suffered two falls between that day and June 3, when she was transferred to Denbigh Community Hospital, a decision which the health board has since admitted was incorrect.

Mrs Anson returned to Glan Clwyd on June 8, and received palliative care before her death on June 13.

In Betsi’s report, it admitted that the ward she was placed on was inappropriate, as this is a respiratory ward and her symptoms were primarily surgical and vascular.

It also accepted that there was “significant miscommunication” between staff and Mrs Anson’s family, in particular relating to her ward moves and the purpose of palliative care.

Her transfer to Denbigh, meanwhile, was labelled a “clear breach of duty, which we truly regret”.

In response, an Ombudsman spokesperson said that, when a decision is taken not to investigate a complaint, a review of that decision may be requested.

That would be the next step Mrs Jones could take, if she wishes to pursue the matter.

Llais Cymru, an independent statutory body set up by Welsh Government to give the people more say in the planning and delivery of health and social care services, has an active advocate acting on Mrs Jones’ behalf in this case.

The organisation was also approached for comment.