Source · PSOW (Public Services Ombudsman for Wales)

Aneurin Bevan University Health Board

PSOW (Public Services Ombudsman for Wales) Upheld Reference PSOW-202401503 Sector Health Category Clinical treatment in hospital Decided 07 April 2025

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Full decision

Mr C complained about the care and treatment provided to his late father, Mr A, by the Health Board. Specifically, the investigation considered whether the Health Board diagnosed Mr A’s hip fracture in a timely manner following his admission to the Royal Gwent Hospital on 7 November 2022.

The investigation found that Mr A’s complaints of right foot and knee pain were investigated in a timely fashion during his admission. However, given his continued difficulty in mobilising and the reference, by a physiotherapist, that Mr A’s pain could be referred from the hip, it would have been prudent for the Hospital to organise a hip X-ray sooner after Mr A’s admission. It is not possible to state with confidence whether an earlier hip X-ray would have evidenced any fracture. However, the lack of an earlier X-ray represented an injustice to Mr C, as he will retain a lingering doubt as to whether Mr A could have been saved some pain and distress. To this limited extent, the Ombudsman upheld this complaint.

The Health Board accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, and remind relevant staff of the importance of carrying out hip X-rays on elderly patients who have a sudden change in their mobility status, which does not improve with therapy.

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