Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Miss P complained about the Health Board’s care and treatment for her fractured wrist, and that it delayed in carrying out surgery. That delay, Miss P said, caused her further pain, a delayed recovery period and anxiety. Miss P is autistic.

the investigation found that, whilst the overall care provided was to an appropriate standard, there had been a lost opportunity to reach a different decision on the management of Miss P’s injury, as the Health Board had not properly discussed with her the option of surgery at an earlier point. There was no evidence that it had made any reasonable adjustments, in accordance with the Equality Act 2010, to account for Miss P’s autism and enable her to properly understand and participate in the decisions about her clinical management (including any earlier surgery). This loss of opportunity contributed to Miss P’s distress and anxiety. To that extent, the complaint was upheld.

The Health Board accepted the recommendations made: to apologise to Miss P for the failings found (within 1 month) and to share the findings with its Equality, Diversity and Inclusion Team to take forward learning points as highlighted in the report (within 3 months).