A woman who underwent a lumbar puncture at Newport’s Royal Gwent Hospital more than two years ago says she has been in severe back pain ever since. Her evidence appears to show there were far more attempts to insert the needle than considered safe by experts.
It comes after WalesOnline revealed a botched lumbar puncture at the same hospital which left another patient, Natalie Ann Dyke, complaining of long-term back pain. The hospital has since admitted breaching its duty of care in that case.
Patient's ordeal
Jane (not her real name), a 30-year-old from Cwmbran who works in housing, contacted WalesOnline after reading about Natalie’s case. Her own experience was disturbingly similar, she said.
She claimed she too had been through a lumbar puncture in which she repeatedly told medics she was in agony only for her concerns to be ignored. Around 16 attempts were made to insert the needle, Jane alleged, and she now lives with debilitating pain.
Like Natalie, she received no substantive response to a formal complaint for months. That did not change until WalesOnline contacted the hospital, which is run by Aneurin Bevan University Health Board. The health board has now promised a clinical review of the case, telling WalesOnline: “We are very sorry to hear about Jane's ongoing pain and the impact this is continuing to have on her daily life.”
Procedure details
Jane underwent the lumbar puncture in March 2024 because she had been struggling with headaches due to her IIH (idiopathic intracranial hypertension) – a condition in which pressure builds up around the brain. The procedure involves a needle being inserted between the bones of a patient's spine so fluid can be collected. In Jane’s case the hospital wanted to learn more about her headaches. She says she did not at that stage have any back problems.
Moments before the procedure Jane allegedly overheard a concerning conversation between a doctor and other medics in the room. The doctor mentioned he was inexperienced in lumbar punctures and not confident with them, she claims.
“This immediately increased my anxiety although I trusted I would still be cared for appropriately,” said Jane. “During the procedure itself I experienced significant pain. Not discomfort, pressure, or mild sensation, but genuine pain. I repeatedly said this out loud while crying throughout the procedure.”
Jane felt she was “not listened to” as three medics made continued attempts to insert the needle during an ordeal lasting around two hours. One of them allegedly kept suggesting she was just experiencing “pressure”, which made Jane feel she was not being believed.
“At no point did I feel reassured, comforted, or properly supported despite my visible distress and repeated statements that I was in pain,” she said. “Suddenly all three clinicians’ devices began ringing, which I assume indicated an emergency elsewhere, and they quickly packed up and left the room. I was not told where they were going, how long they would be, whether I should stay or leave, or what was going to happen next.”
Aftermath and complaint
Jane claims she was left alone in severe back pain. Although struggling to walk she managed to slowly make her way back to the waiting room where she told her partner she wanted to go home. Later one of the clinicians returned and said they wanted to attempt the lumbar puncture again with the anaesthetic team. Jane said she could not go through it again that day because she was already in so much pain. Another nurse later agreed it should not be attempted again that day and arranged for her to return the following week.
Jane claims the medics made a total of 16 to 19 attempts to insert the needle during the first procedure. Her account appears to be supported by pictures from shortly afterwards showing the needle marks in her back, many of which were concentrated around a small area.
Hospital sources have previously told WalesOnline their training made clear that a lumbar puncture should not be attempted more than twice in one sitting, although the health board says its policy does not “specify a maximum number”. Research from the US National Library of Medicine has found the number of attempts is “significantly associated with post-lumbar puncture back pain”. The study concluded: “A total of four attempts is regarded as an acceptable maximum.”
Jane struggled to walk for days after the procedure. Her partner had to help her sit down, stand up, get dressed, and get in and out of bed. “Although the pain eased over time it has never gone away,” she said. “I now live with daily lower back pain.”
The week after the failed procedure Jane returned to the Royal Gwent and had a better experience. “The doctor who performed the lumbar puncture was calm, reassuring, and listened to me,” she said. “When I said something was painful he stopped and adjusted. He did not dismiss my concerns or try to convince me otherwise.” The procedure was successful. So too was Jane’s treatment for her IIH, which is no longer causing her debilitating headaches. But her back pain since the first lumbar puncture has had a massive impact on her life.
“I used to be quite active but now I can’t exercise without a lot of pain. Before this happened I could go on mountain walks. I climbed Pen y Fan. Now if I take the dog for a walk, even in a flat area, my back will be hurting after 10 minutes and I’ll feel like I need to stop. It’s been extremely upsetting.”
Jane was referred by her GP to a physiotherapist but if anything her pain has been worse since she started the exercises and no other support was offered, she says.
Health board response
By January this year Jane had lost hope that her pain would subside over time. She wanted answers over what went wrong during the lumbar puncture so she made a formal complaint to the health board. But the response was that the health board could not investigate because more than 12 months had passed and the complaint was “out of time”. This was despite Jane explaining in her complaint: “It has only become clear over time that this is an ongoing issue rather than a temporary one.”
After her complaint was rejected Jane asked the health board to reconsider. “These issues impact people’s lives and you are putting a [time limit] on it rather than helping the people that have been put in long-term pain due to poor practice,” she wrote. But the health board repeated its refusal to investigate because the concerns were out of time. Only after WalesOnline intervened was there a U-turn as the health board accepted the patient “had only become aware of long-lasting effects in the past year”. It promised to open a clinical review of the case.
Jane told WalesOnline it was an emotional moment to learn the health board had finally shifted its position. But she added: “It’s very concerning that people have to go this far to be heard.”
This echoed the case of Natalie whose family complained last December but did not receive a response until after WalesOnline raised the matter in April. The hospital closed its investigation into Natalie’s concerns without even telling her – but after WalesOnline reported on her traumatic experience a new probe was launched and found “a breach of duty of care”. One of the key issues in Natalie’s case was that a physician associate (PA) had performed her lumbar puncture – despite the British Medical Association stating this is a "must not" in the safe scope of practice for PAs.
Jane does not believe a PA was involved in the procedure she underwent but she is concerned the alleged repetition of failings suggests issues with the hospital’s training. “I don’t want this to happen to anyone else and I would like to finally get some answers,” she said.
No patient should feel their pain is being dismissed, said Natasha Asghar, MS for Casnewydd Islwyn, who told WalesOnline: "Where concerns are raised they must be taken seriously and investigated promptly, rather than patients having to reach a point of desperation before they are heard. The Welsh Government and health boards must ensure that appropriate clinical standards, training and safeguards are in place and followed consistently. If protocols were breached, or mistakes were made, there must be transparency and accountability. Patients deserve honest answers about what happened and, where failings are identified, meaningful action is taken immediately to ensure they are not repeated. I welcome the commitment to review Jane’s case, but this should not have required media intervention. The health service must have a culture where patients can raise concerns confidently and know they will be heard, supported and treated fairly."
A spokesman for the health board said lumbar punctures can be "technically challenging" and that throughout the procedure a patient must be "appropriately informed and their ongoing consent obtained". If a patient withdraws consent, the procedure would not continue, he said. "Under NHS Wales arrangements, concerns should normally be raised within 12 months of the incident or of a person becoming aware of the issue," he added. "In line with those arrangements our previous correspondence was correct. However having considered the information provided, which suggests Jane only became aware of long-lasting effects in the past year, we would like to offer a clinical review of the case and will contact Jane directly to discuss her concerns and any appropriate next steps."
