Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Cardiff and Vale University Health Board
In November 2018 Mrs X attended Llandough Hospital, she was noted to have developed a left foot drop over the last 2 to 3 months. The foot drop corresponded with L4 (the fourth lumbar) and a previous MRI scan showed a disc prolapsed at L5/S1 (at the bottom of the vertical column). In December Mrs X had an urgent MRI scan that showed progressive degenerative changes to L5/S1. On 18 June 2019 Mrs X attended the Hospital, and she was referred for an Electromyogram (“EMG”). The 17 August EMG reported very severe acute and chronic radiculopathy. Mrs X complained about her treatment between September 2018 and August 2019.
The Ombudsman found that an urgent decompression may have benefitted Mrs X, and she should have been assessed before November 2018. He also found that Mrs X had waited too long (7 months) for a consultation to discuss her urgent MRI result, the 21 June MDT had not explained her neurology when the MRI showed compression of the L5 nerve and the EMG, MRI scan and Mrs X’s symptoms were highly indicative of foot drop related to the L5 nerve root. The Ombudsman found that even by taking account of the pandemic, 23 months later, it was unreasonable that Mrs X had not been given the result of the EMG. The Ombudsman also found that Mrs X should have had more urgent assessments and investigations.
The Health Board agreed to implement the Ombudsman’s recommendations within 1 month and apologise to Mrs X for the identified failings, make a redress payment of £2,000, and inform Mrs X of the result of the August 2019 EMG. The Health Board agreed within 6 months to consider e-referrals, ensure patients who have urgent scans are seen within 1 month, ensure patients are given the EMG results in a timely manner, and reviews the Spinal MDT process to consider whether a different approach should be adopted to ensure decompression identification.