Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained that during her admission to the Medical Assessment Unit (“MAU”) within the University Hospital of Wales between 11 and 12 February 2020, based on her reported and observed symptoms, the appropriate investigations were not undertaken (namely a spinal X-ray and a Vitamin D test) nor were appropriate examinations performed (namely an examination by the Trauma and Orthopaedic Team). Consequently, Mrs A said that she was misdiagnosed and as a result has suffered significant physical and psychological trauma.

The investigation found that there had been a failure to arrange Vitamin D and Calcium tests. Whilst these were not clinically indicated in the acute setting of MAU, they formed part of the documented clinical plan. In addition, consideration should have been given to referring Mrs A for an outpatient CT or MRI scan given the osteoporosis risk factors and severe pain she experienced. It was not possible to determine whether the fractures would have been identified earlier if the tests and / or investigations had been performed. Nor was it possible to establish whether earlier identification would have limited the physical pain and psychological ramifications. However, the uncertainty alone represented an injustice to Mrs A.

The Health Board agreed to apologise to Mrs A, provide minutes of a meeting held in April 2022 and to disseminate a circular to the on-call medical team reminding them of the importance of undertaking all aspects of a clinical plan and record if any aspect is repealed. It also agreed to ensure that its Frailty and Osteoporosis teaching sessions outlined the risk factors for fragility fractures and provided an emphasis on early identification and onward referral for management and treatment.