Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms C complained about the care and treatment she received from Betsi Cadwaladr University Health Board for a knee injury. The investigation considered whether the care provided to Ms C at Wrexham Maelor Hospital on 24 June 2020, and at the following outpatient appointment on 13 July, was appropriate. The investigation also considered whether the care given at a physiotherapy appointment on 23 July was appropriate, including whether appropriate action was taken and a second opinion was sought within a reasonable timeframe by the physiotherapist. It also considered whether the second opinion was appropriate. Finally, the investigation considered whether the Health Board response regarding the physiotherapist’s role was appropriate.

The investigation found that while the clinical assessments on 24 June and 13 July were appropriate, the X- ray findings should have been further investigated. However, it was not possible to determine with certainty, even if the Health Board had identified earlier that a magnetic resonance imaging scan (“MRI” – the use of strong magnetic fields and radio waves to produce detailed images of the inside of the body) or treatment was necessary, that they would have taken place sooner or that the outcome for Ms C would have been different. That said, the uncertainty was an injustice to Ms C, so the complaint was upheld. The investigation found that the physiotherapy treatment delivered on 23 July was adequate overall and the management plan to seek an expert opinion was appropriate. The Health Board’s complaint response regarding the physiotherapist’s role was found to be adequate. There was a short delay in seeking a second opinion, but no second opinion was provided, neither did the physiotherapist chase up the referral. However, this was because Ms C advised the physiotherapist she was seeking private treatment. Therefore, these complaints were not upheld.

The Ombudsman recommended that Ms C be provided with an apology for the failings identified and that the Health Board should remind orthopaedic clinicians to further investigate relevant X-ray findings and that it undertake a review of the processes in place to follow up patients presenting with acute symptoms to ensure there is satisfactory resolution of symptoms.