Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr A complained about the treatment that he had received from Hywel Dda University Health Board. He said that the Health Board had failed to diagnose an avulsion (pulling or tearing away) injury to a tendon (strong tissue that connects a muscle to a bone) in his left ring finger on 20 and 23 January 2019. He also said that it had failed to refer him to another Health Body (“the Other Health Body”) for specialist surgical input for his tendon injury promptly.

The Ombudsman found that the fracture diagnosis made by an Emergency Nurse Practitioner on 20 January was, though incorrect, reasonable given the clinical information available to her at that time. However, he found that a Consultant Orthopaedic Surgeon and an Orthopaedic Doctor had inadequately assessed Mr A’s finger injury on 23 January. He also noted that Mr A’s tendon injury would probably have been diagnosed sooner if they had assessed his finger injury properly on that date. He partly upheld the diagnostic aspect of Mr A’s complaint as a result. He found that the Health Board’s referral to the Other Health Body for specialist surgical input had been unreasonably delayed. He upheld the referral part of Mr A’s complaint. He considered that the failings identified had caused Mr A significant uncertainty and distress, in terms of his treatment journey and clinical outcome, which amounted to an injustice.

The Ombudsman recommended that the Health Board should apologise to Mr A for the failings identified. He asked it to share his investigation report with clinical staff. He recommended that it should consider Mr A’s clinical care concerns in a manner akin to the redress arrangements outlined in the relevant complaint handling regulations. He also asked it to update him regarding that consideration. He recommended that it should take action to ensure that it makes referrals for specialist hand trauma-related input promptly and efficiently. The Health Board agreed to implement these recommendations.