Mr A complained about the orthopaedic management and care he received at Betsi Cadwaladr University Health Board’s Ysbyty Glan Clwyd. Specifically, Mr A’s complaint centred on the appropriateness of the decision to refer him for specialist intervention in 2023 for a non-healing fractured femur (thigh bone) and for him to limit weight-bearing on that leg. Mr A was concerned that this delayed physiotherapy input and his recovery.
The Ombudsman’s investigation concluded that it was clinically appropriate for Mr A to be partially weight-bearing (“PWB”) on that leg between August and October 2023, given there were areas where Mr A’s femur was not healing. However, the Ombudsman identified that an updated X-ray should have been carried out before the decision to make a specialist referral and for Mr A to continue PWB was made in the December. Had this happened, X-rays might have shown that Mr A’s femur was healing and therefore prompted a change in his PWB status.
The investigation identified that during the significant time (December 2023 to May 2024) that Mr A remained PWB, there were inadequacies both in monitoring and progressing the specialist referral and in follow-up clinic reviews. Mr A will have to live with the uncertainty of not knowing whether the degree of physiotherapy input that would have assisted his recovery could have happened sooner. This is an injustice to him. It was to this extent that Mr A’s complaint was upheld.
The Health Board agreed to carry out a number of recommendations. These centred on apologising to Mr A, clinician learning through the sharing of this report, and in terms of onward specialist referrals, that it review and evidence to this office that there are effective mechanisms in place for clinicians to monitor and to check progress on these referrals, or provide an action plan setting out how this will be achieved.