Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment outside hospital

Case Reference Number



Not Upheld

Mrs X complained about the care and treatment her daughter, Miss Y received following a shoulder fracture in March 2019. In particular, Mrs X was unhappy at the decisions taken around the deterioration in Miss Y’s skin over the following 7 weeks.

The Ombudsman’s investigation found that the Health Care Support Workers (HCSW) that undertook passive physio movements of Miss Y’s limbs were appropriately trained and carried out the exercises appropriately, coupled with there being some concerns about Miss Y having a low bone density, it could not be said for certain how the fracture of Miss Y’s shoulder occurred. The Ombudsman found no fault with the HCSWs.

With regard to the deterioration in Miss Y’s skin, there were concerns in relation to Miss Y’s skin prior to her shoulder fracture and her general condition along with her incontinence and immobility meant her skin was more vulnerable to deterioration. However, the Ombudsman was satisfied that the actions of the HCSWs, the GPs and nurses who visited Miss Y at home were appropriate, that referrals were made in a timely fashion and every possible solution was sought to improve the condition of Miss Y’s skin.

The Ombudsman did not uphold the complaint.