Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

The investigation found that aspects of Mr A’s care and management in relation to his hip injury were reasonable and appropriate. However, given that there was evidence of osteoarthritis in Mr A’s right hip, a lateral view X-ray should have been obtained especially as the X-ray did not rule out advanced osteoarthritis. The investigation also found that inadequacies in Mr A’s management led to him only receiving an injection into his left hip, instead of the planned injections into both hips and the joint. The Ombudsman was of the view, given Mr A’s presentation and medical history, a referral to the pain team for management of Mr A’s symptoms was reasonable and appropriate. However, she was critical of the Surgeon’s decision to discharge Mr A as this meant that Mr A felt that he needed to seek a second opinion for his ongoing symptoms and was unable to make fully informed decisions about his care and management which was an injustice to him. The Ombudsman was pleased to note that the Surgeon has reflected on his management of Mr A’s care and identified shortcomings and areas of improvement for his future clinical practice. Finally, the investigation found that the Health Board’s investigation and subsequent complaint response was not sufficiently robust as it did not identify the failings in Mr A’s care that the Ombudsman’s investigation found. Given the shortcomings identified these parts of Ms A’s complaint were upheld and the Health Board was asked to apologise to her and her father.