Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs L complained about the assessment, care and treatment given to her mother, Mrs M, by the Health Board when Mrs M presented at the Emergency Department following a fall on 21 July 2022. Ms L explained that, a month later, an X-ray found that Mrs M had a hip and pelvis fracture.

The Ombudsman found that the documented assessment of Mrs M was not of an appropriate clinical standard. It overlooked her moderate pain score and did not explore the cause and location of her pain. There was no examination of Mrs M’s range of movement in her hips or her ability to weight bear. A more complete assessment might have identified tenderness, limited movement and/or immobility which, in turn, should have prompted an X-ray. The consequent uncertainty as a result of the missed opportunity to identify (or exclude) the presence of a fracture is an injustice. This is because we cannot know what more might have been done for Mrs M and what difference that might have made to her in the weeks following.

The Health Board agreed to apologise to Mrs L for the shortcomings identified in the Doctor’s assessment, and the outstanding uncertainty about what an X-ray might have identified if it had been taken on 21 July. It also agreed to remind staff of the importance of documenting the site and type of pain when documenting a patient’s pain score, and of carrying out a full hip and pelvis examination in patients who are at high risk of fractures from falls. The Health Board agreed to complete these actions within 1 month.