Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Early resolution

Mrs X complained about the fact that Cardiff and Vale University Health Board used a right-sided knee replacement component being used when she underwent a left-sided total knee replacement. She said that the Health Board failed to explain the implications of the wrong sided prosthesis being used.

The Ombudsman found that whilst the Health Board had admitted to a failure in its procedures, it had not explained to Mrs X about any possible implications for her, nor what aftercare it intended to provide intended to monitor Mrs X’s clinical condition. This situation resulted in Mrs X experiencing stress and worry about the uncertainty.

The Ombudsman contacted the Health Board and in resolution of Mrs X’s complaint it agreed to, within 20 working days, arrange a meeting with Mrs X to assist her with understanding the implications of having the wrong sided knee prosthesis fitted together with an explanation about the type of aftercare she would receive to monitor the situation.