A health board has apologised to relatives of a man who died waiting to get an appointment for his heart condition at Bangor's Ysbyty Gwynedd.
The patient, referred to as Mr Y, died on July 20, 2016, the day before a letter arrived inviting him to make an "urgent" appointment.
The man's brother, Dr X, complained that the GP's referral to the clinic was not acted upon in a timely manner.
Betsi Cadwaladr University Health Board has said it is implementing changes.
The Public Services Ombudsman for Wales found that Mr Y, who died of ischaemic heart disease, should have been seen at the rapid access chest pain clinic (RACPC) within seven days of his GP's urgent referral.
The letter for an appointment was sent to Mr Y 12 days after the referral, despite a consultant identifying his heart readings as abnormal and suggesting it was an emergency.
The ombudsman said it was also unacceptable that Dr X had waited four months for a "meaningful response" from the health board to his initial complaint.
Betsi Cadwaladr UHB agreed to apologise to Dr X and to Mr Y's partner for the delay in both the appointment and the response.
It also agreed to review:
The percentage of referrals to the RACPC not triaged within 24 hours or the next working day
Whether job plans need to be modified or more cardiologists used to deliver RACPC "in a timely manner"
Consider developing a protocol for GP referrals to RACPC
'Unacceptable delay'
Reena Cartmell, the health board's deputy director of nursing and midwifery, said: "We apologise that we did not deliver the standard of care that we should have and for the unacceptable delay in responding to the family's complaint."
"We have taken note of all of the ombudsman's comments and are in the process of implementing all the recommendations he has made."
She said the board was also "working hard" to improve its concerns process.
Cuddled from BBC
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