Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms D complained about the treatment she received at the Emergency Department (“the ED”) of the University Hospital of Wales (“the UHW”) when clinicians misdiagnosed an injury that she sustained to her left ankle following a fall. Ms D complained that, after reviewing an X-ray, an Emergency Nurse Practitioner (an ENP) diagnosed and treated her injury as a Grade II sprain. However, an X-ray report, which was not seen by ED clinicians until several days later, confirmed that she had sustained an undisplaced fracture to the tip of the lateral malleolus (the bony prominence on the outer edge of the ankle).

Ms D complained that it was several weeks before she was informed of this misdiagnosis and that, during this time, the pain and swelling increased to the point where her GP referred her for a further X-ray, which confirmed the fracture. Ms D complained that, as a result of this, her recovery was delayed.

The Ombudsman did not uphold Ms D’s complaint that the misdiagnosis led to her recovery being delayed. Whilst he established that the misdiagnosis did occur (and asked the Health Board to reflect on this), he was satisfied that the treatment for this type of fracture and a Grade II sprain are the same (as are the recovery time and prognosis). Given this, there was no evidence that the misdiagnosis led to any adverse clinical consequence.

However, the Ombudsman found that the Health Board was slow to identify that a misdiagnosis had occurred and failed to ensure that Ms D was explicitly informed of this. Whilst it wrote to her recommending a physiotherapy follow-up, it did not inform her of the reason for this, nor did it ensure that the physiotherapist was made aware of the matter.

The Ombudsman considered that clinicians failed to observe their duty of candour (in accordance with GMC Guidance) and that this, together with the additional inconvenience to Ms D of having to reattend the UHW, was an injustice to her. The Ombudsman also concluded that failings in the Health Board’s complaint response left Ms D little option than to escalate her complaint to his office.

The Ombudsman recommended that the Health Board provides Ms D with a fulsome apology for these communication failings and, in recognition of the avoidable time and trouble to which she was put in pursuing her complaint, makes a payment to her of £250.

The Ombudsman also recommended the Health Board shares the report with the relevant ED clinicians and conducts a review of its X-ray recall system – in particular: the standards for radiology report review within the ED, the information given to patients and the content of recall letters where a misdiagnosis has occurred, and the content of referrals to physiotherapists as part of the recall process.

Finally, the Ombudsman recommended that the report is shared with the Concerns Team and that the shortcomings identified in the Health Board’s complaint response letter are reflected upon.

The Health Board accepted and agreed to implement these recommendations.