EditorHYWEL DDA: Health board pays out after patient left with ‘significant sight impairment’ following ‘serious failings’
A damning report from the Public Services Ombudsman for Wales found the health board missed multiple opportunities to treat the patient, known as Mrs B, who was “lost to follow-up” for seven years.
The investigation found that clinicians failed to act on advice from another health board in 2012, did not carry out appropriate tests, and cancelled 11 appointments while the patient’s condition worsened.
The Ombudsman’s report concluded that if Mrs B had received appropriate care, she would likely have “retained useful vision in her right eye.”
Instead, the “devastating impact” has resulted in her losing her confidence and independence, becoming depressed and isolated, and now requiring care to live at home.
The health board has been ordered to pay Mrs B £4,500 for the “serious failings” and a further £300 for the time and trouble she was put to in pursuing her complaint.
Sharon Daniel, Director of Nursing, Quality and Patient Experience at Hywel Dda University Health Board, offered an unreserved apology.
“We acknowledge the findings of the Ombudsman’s report and we are sorry for the failings identified and the impact on the patient who was under our care and her family,” she said.
“We recognise that there were significant failures in the way we approached the treatment of our patient that led to her suffering significant sight impairment. We apologise unreservedly for these failures.
“This is not the level of service we wish to provide our patients and we will strive to do better.”
The Ombudsman’s investigation highlighted that even during the COVID-19 pandemic, no assessment was made of the risk to Mrs B’s sight, despite guidance stating that imminently sight-threatening conditions “MUST CONTINUE” to be treated.
The report also criticised an “inadequate” review in March 2022, where relevant tests were not done and an opportunity was missed to make an earlier referral for specialist treatment.
Ms Daniel confirmed the health board accepted the Ombudsman’s recommendations and had started to implement improvements.
These include increased staffing levels, a new glaucoma co-ordinator role, and a better system for categorising patients based on their risk of vision loss.
The health board is also installing a new electronic patient record system, ‘Open Eyes’, to improve record keeping and ensure seamless information sharing with neighbouring health boards like Swansea Bay University Health Board.
#Carmarthenshire #HywelDdaUniversityHealthBoard #NHSWales #Ophthalmology #patientSafety #PublicServicesOmbudsmanForWales
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