Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Miss A complained about the care provided to her father, Mr B, by the Health Board between January and July 2020. The investigation considered whether the Health Board failed to diagnose Mr B’s cauda equina syndrome (“CES” – a rare and severe type of spinal stenosis – where the bundle of nerves at the bottom of the spine, called the cauda equina, become compressed. The cauda equina control the function of the bladder and bowel, as well as skin sensation). Miss A also complained that the Health Board failed to expedite Mr B’s appointment to another health board when his condition deteriorated and failed to provide him with suitable aids during this time, despite his deterioration.

The Ombudsman found, on balance, that, whilst she did not consider that an AdvancedPhysiotherapy Practitioner (“APP”) should have made a definitive diagnosis of CES when Mr B was first seen on 16 January 2020, there was inadequate clinical evidence that the APP had explored Mr B’s longstanding urinary dysfunction sufficiently. The Ombudsman considered that, whilst it is not now possible to determine with certainty whether Mr B had CES that needed urgent intervention at the time, had there been sufficient exploration at the time of the consultation this uncertainty might have been avoided. The complaint was therefore upheld on this basis.

The Ombudsman found that there was no failure to expedite Mr B’s appointment with the Spinal Unit at the other health board and that there was no failure to provide suitable aids to Mr B. This complaint was not upheld.

The Ombudsman recommended that the Health Board apologise for the shortcomings identified and to pay redress of £350 to Miss A for the uncertainty caused. The Health Board said, during the course of the investigation, that it had taken a number of actions to improve its service(including putting in place a cauda equina pathway, reviewing and standardising its letters, and delivering training to relevant physiotherapists across the Health Board to improve the clinical screening of CES). The Ombudsman recommended that the Health Board provide her with evidence of the measures it has taken within 3 months.