Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Voluntary settlement

Mrs A complained about her nursing care during an admission to Ysbyty Glan Clwyd after fracturing her spine in a fall. Mrs A said that the Health Board failed to maintain spinal precautions (“SPs” – to stop movement of the spine to prevent injury to the spinal cord) causing her nerve damage and ongoing problems with pain and mobility.

The investigation identified occasions during her admission when Mrs A was noted to be in some form of sitting position although she should have been laid flat until imaging was available to show how stable the fracture was, and if it was safe for her to move around. There was no evidence of clear communication from the Medical to the Nursing Team about the need for SPs and nursing care plans for patient handling and toileting that would have communicated the need for SPs were not put in place. Further, several phrases were used in records to mean SPs which had the potential to cause confusion and error. However, later imaging of Mrs A’s spine showed that the fracture was stable and that it was safe for her to move around. There was also no nerve damage identified. As there was no evidence of a direct link between the failings in Mrs A’s care and her ongoing health issues, the investigation was brought to a close.

In response to the findings, the Health Board initiated specialist training on manual handling for all staff, improved signage, and a visual safety board to identify patients who needed SPs in place. To settle the complaint, the Health Board also agreed to apologise to Mrs A for the failings in her care and the worry she was caused, to share the learning from the complaint with relevant staff, and to decide common terminology for SPs to ensure consistent and safe communication.