Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained that the Health Board failed to provide appropriate care and treatment to her daughter, Child B, after she sustained an elbow injury on 30 March 2020 and failed to provide an appropriate complaint response to her concerns.
The Ombudsman found that the Health Board could have referred Child B to a specialist Paediatric Orthopaedic Surgeon sooner and, whilst this may not have altered the clinical outcome, the delay caused additional distress and uncertainty for both Child B and Mrs A. This additional distress was an injustice, and this aspect of the complaint was upheld.
The Ombudsman was satisfied that the Health Board handled Mrs A’s complaint appropriately, including providing her with an acknowledgement, updates, and information about how to escalate her concerns if needed. This part of the complaint was not upheld.
The Ombudsman recommended that, within 1 month, the Health Board should provide Mrs A with a written apology for the failings identified in this report and that, within 3months of the final version of this report being issued, the Health Board should provide the Ombudsman with evidence that it has reflected on the failings identified in this report and reviewed its processes regarding the management of paediatric fractures accordingly, including a robust process for the onward referral of complex paediatric fractures.