A woman’s sepsis death following a misdiagnosis was a “grave injustice” and may have been preventable, a report has concluded.

The Public Services Ombudsman for Wales found that the woman, referred to only as Mrs K, could have survived if she had received appropriate treatment for her acute pancreatitis “from the outset”.

Mrs K, a patient at Wrexham Maelor hospital, died on 31 January 2022 from biliary sepsis, a serious infection of the bile ducts.

Betsi Cadwaladr health board has apologised “unreservedly” as well as directly to the woman’s daughter for the failures identified in her mother’s care.

The ombudsman found the health board had “missed opportunities” in correctly diagnosing and treating Mrs K, including the failure to identify her gallstones.

It also found “little to no evidence” that the seriousness of her condition had been appropriately communicated to her and her family.

Public Services Ombudsman for Wales, 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”.

She said: “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 said she was also “deeply concerned” at the health board’s seeming “lack of candour” in its response to the complaint.

She added that clinicians during her investigation showed a “lack of objective reflection” and “continued to fail to identify and acknowledge failings in Mrs K’s care”.

She went on to say that she was mindful the episode of care occurred during a time of Covid restrictions, but said that even with those in place the patient would have been able to access appropriate treatment within a few weeks.

The ombudsman has recommended Betsi Cadwaladr health board offer a full apology from its chief executive to Mrs K’s daughter and to pay her £4,000.

It also said the case should be reviewed by the health board to determine how Mrs K’s was misdiagnosed.

In a statement, Betsi Cadwaladr boss Carol Shillabeer 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.”

It added it was sending “a direct letter of apology” to the patient’s daughter “to assure her that we addressing concerns raised”.