A patient in the care of Betsi Cadwaladr University Health Board (BCUHB) has suffered permanent sight loss and will need life-long treatment as a result of inadequate vascular services, according to the Public Services Ombudsman for Wales.
BCUHB has issued an apology.
The Ombudsman launched an investigation after Mr L complained about the care and treatment he received from Betsi Cadwaladr University Health Board in 2018.
Mr L said the BCUHB failed to promptly and appropriately identify, investigate and treat a blockage of blood vessels in his neck and also complained they did not provide him with timely care once the blockage had been identified in September, up to his surgery in November 2018.
The Ombudsman found BCUHB missed opportunities to consider the possibility he suffered a watershed stroke. Had Mr L undergone an appropriate scan, he would have likely been offered surgery as a matter of urgency. Mr L was seen at hospital two months later and there was a further failure to properly investigate the cause of his ongoing symptoms.
It was not until six months later an appropriate scan was arranged, revealing the issue.
The Ombudsman also found BCUHB delayed treating the blockage following the diagnosis, even though Mr L suffered small temporary strokes during the scan , and in the weeks that followed. Damage to the eye and loss of vision because of reduced blood flow were identified from the scan in September, which called for urgent surgical treatment.
Mr L eventually underwent surgery on 8 November. He has been left with permanent sight loss and life-long treatment to try to manage his ongoing pain, inflammation, and increased pressure because of the damage caused to his eye.
Public Services Ombudsman for Wales Michelle Morris said: “As a result of the repeated missed opportunities to identify and treat his vascular condition, Mr L suffered multiple strokes, ongoing discomfort, and blurred vision. Despite the irreversible nature of the condition affecting his eyesight, there still appeared to be no sense of urgency to offer treatment.
“These missed opportunities amount to significant service failures - they caused significant and ongoing injustice to Mr L because he continues to experience debilitating symptoms.
“Clearly, there was a complete failure to follow the relevant guidelines and the Health Board’s own policy.
“In addition, I cannot fail to be shocked by the fact that although Mr L first complained to the Health Board in June 2019, it took until February 2023 for it to recognise any failings – and that only after reviewing a draft of the professional advice informing our investigation. We have recently published a strategic report ‘Groundhog Day 2’ highlighting that we continue to see these kinds of failings across the Health Boards in Wales.”
“We had noted similar failings in a previous case we investigated against the Health Board. Since that investigation, 2 reports were published that were extremely critical of vascular care and treatment at the Health Board. However, I am aware that recent review of these services by Health Inspectorate Wales pointed to notable improvements. This gives us hope that events such as in this case might in future be avoided.”
The Ombudsman recommended that Betsi Cadwaladr University Health Board should apologise to Mr L and pay him £4750 for the failings she identified and the impact upon him.
In addition, the Ombudsman recommended BCUHB should:
• remind all relevant staff that all patients who may be appropriate for surgery should undergo scans of the major arteries in the neck (carotid arteries).
• remind all relevant staff of the clinical indications of the types of strokes that affected Mr L and of the importance of considering this possibility when reviewing patients.
• ensure that the treating Consultant reflects on how they can improve their future practice in light of the Ombudsman’s findings.
• review its policy about treatment to ensure that it is compliant with current guidance and share the revised policy with staff.
Dr Nick Lyons, Betsi Cadwaladr University Health Board’s executive medical director, said: “I apologise unreservedly to ‘Mr L’, on behalf of the Health Board, for the failures identified in his treatment.
“Despite this incident taking place in 2018, the Ombudsman noted a number of areas for improvement and we have accepted her findings in full. We have made significant progress in some areas but recognise there is more to do.
“We also note her comments surrounding our complaint handling and responses. I want to assure residents in North Wales the Health Board takes its Duty of Candour, the contract we have with the public to be open and honest, extremely seriously.
“We know we can only win the public’s trust, and provide services it has confidence in, by being fully transparent in our investigations.
“While we welcome the Ombudsman’s acknowledgement of the good progress and significant headway made in vascular services recently, we will continue to provide strong oversight and governance of the specialty.”
Commenting on the news that Wales' largest health board has said it apologises "unreservedly" after treatment delays led to a patient losing the sight in an eye, Welsh Conservative Shadow Health Minister, Russell George MS said:
"This atrocious example of a life-changing delay is a symptom of wider Labour failure to run our Welsh NHS properly.
“Despite recent announcements around funding, the health budget has still been cut in real terms this year, placing us in a uniquely disadvantaged position compared with the other nations. Just remember, Labour-run Wales has over 27,000 patients waiting 2-years for treatment, Conservative-run England has just 261.
“Betsi Cadwaladr must take on board the ombudsman’s recommendations and be transparent with the public on the outcome of the review.”
Also commenting, Welsh Conservative Shadow North Wales Minister, Darren Millar MS said:
“Unacceptable ophthalmology waiting times have been persistent issue in North Wales for many years.
"How many more people in the region need to lose their sight before the Welsh Labour Government and the Betsi Cadwaladr University Health Board will take the action necessary to get to grips with delays.
“The people of north Wales deserve better.”