Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs F complained about the actions of Cwm Taf Morgannwg University Health Board (“the Health Board”). Mrs F said:
• Following a neck injury in May 2019, the Health Board failed on 2 occasions to diagnose a crushed vertebra.
• A physiotherapist failed to refer her for further investigations when her condition did not improve.
• There was poor communication and inconsistent advice from staff about how to manage her crushed vertebra injury.
• The Health Board did not explain why it chose not to use its discretion, to accept complaints outside of the 12-month period, when rejecting her complaint.
The Ombudsman’s investigation found:
• The examination and assessment Mrs F received following her second visit to the Emergency Department (“ED”) was substandard, and had national guidelines been followed, it was likely that her crushed vertebra would have been diagnosed sooner, as would her diagnosis of multiple myeloma. This complaint was upheld.
• Based on Mrs F’s presenting symptoms, there was no evidence that the Physiotherapist failed to refer her on for further investigations. This complaint was not upheld.
• Whilst the management of Mrs F’s injury was appropriate, it was not possible to reach a finding about the communication and advice given to Mrs F.

• The Health Board failed to explain why it chose not to use its discretion when rejecting Mrs F’s complaint. It also failed to seek comments from its ED team and if it had, it would likely have not only accepted Mrs F’s complaint but also upheld it. This complaint was upheld.
The Ombudsman recommended that the Health Board apologise to Mrs F, make a redress payment of £750 in recognition of the substandard ED assessment, make a further redress payment of £250 in recognition of its poor complaint handling and the time and trouble in bringing her complaint to the Ombudsman. The Ombudsman also recommended that the report was shared with the ED clinicians involved in Mrs F’s care during her second assessment and at an appropriate Consultant forum so lessons could be learnt and improvements made. In addition, the Ombudsman recommended that the report was shared with the Health Board’s complaint handling staff.
The Health Board agreed to these recommendations.