Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

We investigated a complaint from Ms B about the care and treatment provided to her sister, Ms F, by the Health Board between August 2019 and November 2021. Ms F had metastatic cancer and suffered a pathological fracture of the left femur in August 2019 (a fracture which is caused by disease rather than injury).

The investigation considered whether 3 operations relating to Ms F’s fractured femur – carried out between September 2019 and September 2021 – had been carried out to a clinically appropriate standard and whether the cause of the broken nail in Ms F’s femur following 2 of the operations was due to any failure in clinical care. In relation to the third surgery, we investigated Ms F’s post-operative management and communication between clinical teams.

The Ombudsman found that the surgery in September 2019 was of a clinically appropriate standard but that there was a lack of ongoing surveillance. The second and third surgeries and post-operative care fell below a reasonable clinical standard.

While wound management following the third surgery fell within appropriate standards of care, the Ombudsman found that it would have been good practice to obtain plastic surgical input in relation to wound management. There was also insufficient documentation to support that communication was appropriate between clinical teams.
The Ombudsman upheld Ms B’s complaints. The Health Board agreed to apologise to Ms B for the identified failings, review the case against orthopaedic guidance for management of metastatic disease for learning, and to remind the orthopaedic team about the importance of documenting discussions between teams and about the option to consult plastic surgeons in more complex cases involving wound breakdown.