Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms B complained about the care provided to her partner, Mr L, when he went to hospital twice in late 2019, following seizures. She said there was a delay identifying Mr L’s shoulder fracture and failures to undertake CT scans and mitigate Mr L’s risk of harm if he suffered further seizures while in hospital. She also said that there was a delay in providing Mr L with a Neurology appointment.

The Ombudsman found that assessment of Mr L’s shoulder was inadequate, that an X-ray report identifying the fracture was delayed and that poor documentation around the X-ray suggested it had not been reviewed appropriately. He also found that the 7-month wait before Mr L was offered a Neurology appointment was unreasonable, especially in the absence of an accessible point of contact for Mr L to help ensure he remained informed of the reasons for the delay and how to ask for advice in the meantime. Whilst there was no clinical impact of this delay, it increased Mr L and Ms B’s anxiety around his health. The Ombudsman upheld these elements of the complaint.

The Ombudsman found that Mr L’s neurological assessment when he attended hospital was appropriate and that he was appropriately referred to Neurology. Whilst a CT scan should have been undertaken straight away, this had not led to any impact for Mr L because a subsequent CT scan was reported as normal. He also found that appropriate safeguards were in place to reduce the risk of harm to Mr L should he suffer another seizure in hospital. The Ombudsman did not uphold these elements of the complaint.

The Health Board agreed to apologise to Ms B and Mr L, and offer Mr L £750 in recognition of the shortcomings in his case within 1 month. It also agreed to ensure learning was taken from the findings and review the process for emergency X-rays reporting and documentation within 3 months. Within 6 months, the Health Board agreed it would take action to ensure appropriate, agreed timescales for X-ray reports are being met. Finally, it agreed to take steps to ensure that an accessible point of contact is offered, including to patients who have been referred to Neurology, but for whom there is an unavoidable delay in offering an appointment.