Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs G complained about the care and treatment provided to her late husband Mr G, by Hywel Dda University Health Board between September 2019 and March 2020 following a shoulder operation. Mrs G was concerned that:

a) The Health Board failed to adequately investigate and treat Mr G’s ongoing shoulder problems in a timely manner, which left him in constant pain and unable to carry out many normal daily activities.

b) The Health Board’s communication with Mr G was poor. Mrs G was concerned that staff did not take proper account of what Mr G was telling them about his pain and that his shoulder was dislocating. In addition, following an operation in November 2019, the Surgeon spoke to Mr G while he was still recovering from the anaesthetic and Mr G was unable to take in what he was told. Mrs G says that Mr G was not then given a further opportunity to speak to the Surgeon.

c) Despite telling nursing staff that he was allergic to a type of dressing, this continued to be used, causing burns and blistering to Mr G’s skin.

d) When Mr G was discharged home following the operation in November 2019, he was told that district nurses would visit to change his dressings; however, a district nurse only visited once and told him he would need to go to his GP surgery instead. This caused Mr G considerable difficulties as his shoulder problem meant he was unable to drive.

e) The Health Board’s response to Mr G’s complaint failed to adequately address his concerns and contained inaccuracies.

The Ombudsman found that the Health Board’s initial investigation and treatment of Mr G’s shoulder problem was appropriate. However, more detailed imaging could have been obtained before carrying out a subsequent operation, and the decision made at that operation to carry out a hemiarthroplasty (half-joint replacement) was unlikely to have led to the best outcome. This complaint was partly upheld. The complaint that the communication with Mr G was poor was also partly upheld, in relation to the lack of opportunity to discuss his concerns after his surgery in November 2019. The complaint about the dressings was not upheld as there was no evidence that the nursing staff used dressings to which Mr G was allergic, and the skin problems he experienced were likely due to another cause. The complaint about the cancellation of district nursing visits was not upheld as it was not unreasonable in the circumstances for the district nurses to conclude that Mr G was able to attend his GP Surgery. Finally, the matter about the Health Board’s response to the complaint was partly upheld to the extent it did not address the concerns about the cancellation of district nursing visits.

The Ombudsman recommended that the Health Board apologise to Mrs G for the failings identified in the report and provide evidence that it had shared the report with its Trauma and Orthopaedic surgeons who carry out shoulder operations to provide an opportunity for learning.