Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr X complained whether:
• It was clinically appropriate to have removed his daughter’s (Miss X) gallbladder in 2017
• Her diagnosis of superior mesenteric syndrome (“SMAS”) was timely.
• Miss X’s scoliosis was appropriately diagnosed as mild by a Physiotherapist when a private Consultant Neurosurgeon described it as a severe thoracic scoliosis.
• Despite agreement that Mr and Mrs X would be invited to attend MDT meetings, they were not.
• Miss X’s custom made sling was removed and not replaced.
• Mr and Mrs X were not supported or given manual handling training for Miss X.

The Ombudsman found that Miss X’s gallbladder removal was reasonable. He found that the diagnosis of SMAS is difficult, often made late but there was no evidence of a failure of care, accordingly he did not uphold this aspect of the complaint. He also found that the presence, location and whether Miss X’s scoliosis was flexible to manipulation was noted. The Ombudsman found that Mr and Mrs X attended a MDT meeting and were provided with minutes and recording of the meeting, but there were no further MDT meetings, as a result, these aspects of the complaint were not upheld.

The Ombudsman found that while it is unreasonable that Miss X remained without a sling, many attempts were made to achieve this, thwarted by events outside the Health Board’s control. He found that the lack of documentation whether Mr and Mrs X were shown how to support Miss X and that they were not offered a manual handling course were service failures and on this basis the complaint was partly upheld.

The Health Board agreed to implement the Ombudsman’s recommendations within a month and apologise to Mr and Mrs X for the identified failings. It agreed within 3 months to remind staff that advice given when a sling is removed should be documented; to ensure manual plans are in place including contingency plans for the non-availability of slings and to offer Mr and Mrs X manual handling training.