A woman’s death could potentially have been avoided had she received appropriate medical care from Betsi Cadwaladr University Health Board, a report by the Public Services Ombudsman for Wales revealed.

The Ombudsman launched an inquiry after Mrs L complained about the care and treatment her mother, Mrs K, received from the health board between January 2021 and her death on January 31, 2022.

Mrs K passed away from biliary sepsis.

Following an extensive investigation, the Ombudsman discovered a lack of evidence suggesting the healthcare team effectively communicated the severity of Mrs K's condition to her and her family.

The Ombudsman also concluded that Mrs K's acute pancreatitis could have been successfully treated, which could have prevented her deterioration and death.

Michelle Morris, the Public Services Ombudsman for Wales 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."

Ms Morris 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."

She also mentioned that it took place during the pandemic saying: "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."

In reaction to the findings, the Ombudsman has recommended several measures be taken by the Health Board.

These recommendations include issuing a full apology to Mrs L from the chief executive, awarding Mrs L £4,000, reviewing this case to gain insight into Mrs K's misdiagnosis and report the findings to its Quality and Patient Safety Committee and in its Annual Report on the Duty of Candour.

They also recommend revising how they handled Mrs L's original complaint in line with the Duty of Candour, and that they share the report with the clinical director responsible for the consultants involved in Mrs K’s care so that the findings are reflected upon and discussed with the consultants.

Betsi Cadwaladr University Health Board has taken on board the Ombudsman's conclusions and is set to follow through with the recommendations laid out in the report.