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 his wife’s care and management following an injury to her shoulder on 23 January 2020. Mr A also complained about the Health Board’s handling of his complaint.

The Ombudsman’s investigation found that Mrs A’s care and management were broadly reasonable. However, shortcomings were identified during an assessment on 24 January 2020, including the application of an incorrect diagnostic test and a failure to seek consent prior to carrying out a superficial examination. Although the treatment plan and outcome would not have altered as a result, Mrs A was unable to make fully informed decisions about her future management which caused her an injustice. Mr A’s complaint was upheld to that limited extent.
The Ombudsman also found that the Health Board failed to address Mr A’s concerns when he first raised them directly with the Orthopaedic Team. Further, although the Health Board had apologised for the shortcoming, it did not reflect on what had happened and identify any learning to prevent a recurrence. However, when Mr A raised his concerns a second time, the Health Board appropriately acknowledged shortcomings in Mrs A’s care and identified opportunities for reflective learning around the assessment and record keeping. The Ombudsman upheld Mr A’s complaint to the extent that he had to make his complaint a second time to obtain an appropriate response which caused him to lose confidence in the process and unnecessary time and trouble.

The Ombudsman recommended that the Health Board should apologise to Mr A for the complaint handling failings and remind the Orthopaedic Team of the importance of documenting key assessments.