Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr A complained that, following a Child Protection Medical Examination to investigate unexplained bruising to his 8 week old grandson, X, staff at the Health Board identified further potential injuries, most significantly one they identified as a skull fracture. This led to a multi-agency decision to remove X from his parents’ care and place him with Mr A. When the case went to court a specialist found that it was more likely that the skull fracture was a naturally occurring suture and X was returned to his parents. Mr A complained about the actions of the Health Board, about comments that were made by Health Board staff relating to whether he was suitable to look after X, and the Health Board’s complaint response.

The investigation found that the radiologists involved should reasonably have been expected to know about possible alternative diagnoses and should have identified these in their reports. This was a failing and these elements of the complaint were upheld, with the caveat that it was not possible to establish the extent to which this would have influenced the paediatricians’ safeguarding report.

However, as the ‘skull fracture’ was never established to be conclusively misdiagnosed and the decision to remove X was not made by the Health Board, the investigation found that the Health Board would not have been expected to express regret or culpability in its complaint response to Mr A. It also found that, given the information available to the paediatricians, the finding that the ‘skull fracture’ was most likely a non-accidental injury was a reasonable conclusion, and that X-rays were a required part of the safeguarding process. These elements of the complaint were therefore not upheld.

Finally, the investigation found that while it would not be appropriate to restrict what comments staff could make if they had child protection concerns, the way this was handled (both at the time and in response to Mr A’s subsequent formal complaint) could have been improved, and this element of the complaint was therefore partly upheld.

The Ombudsman recommended the Health Board should offer Mr A an apology for the failings identified, and a payment of £1000 in recognition of the lack of reference by the radiologists of a possible alternative diagnosis, and issues with the complaint handling. She also recommended that the Health Board should share the Ombudsman’s report with all radiology staff with involvement in paediatrics, consider if further training is needed for radiology staff, and remind all staff of the importance of outlining possible alternative diagnoses in relevant reports even if 1 is considered to be more likely. Finally, she recommended that it should consider providing guidance to all staff regarding how to respond to individuals contacting them for information they cannot provide, and remind staff involved in complaint handling to address all concerns raised.