Mrs C complained about whether the standard of care provided to her mother, Mrs B, for the management of her cataract (when the lens in the eye develops a cloudy patch) to her right eye was clinically appropriate and timely.
The investigation found that Hywel Dda University Health Board (“the Health Board”) did not respond appropriately to advice it requested from a Second Health Board regarding Mrs B’s care. During the COVID-19 pandemic when public health measures which were put in place to prevent the spread of infection I have seen no evidence that the Health Board considered guidance in place at the time to assess the risk this would cause to Mrs B. When Mrs B was seen again, following the easing of these measures, the review she underwent was inadequate. Relevant tests were not undertaken, a letter to her GP regarding medication was insufficiently detailed and an opportunity was missed to make an earlier referral for further treatment. During the period of time under investigation Mrs B experienced numerous cancelled clinic appointments.
These are significant service failings. Mrs B, who is blind in her left eye, is now also significantly sight impaired in her right eye. Mrs C has described the devastating impact this has had on both Mrs B and her wider family. I also consider that the failures in this case are ones from which other health boards can learn. I have seen no evidence the Health Board assessed the potential harm to Mrs B when cancelling clinic appointments. Earlier opportunities to identify the seriousness of Mrs B’s condition, and to refer her for further treatment, were also missed.
The Ombudsman made a number of recommendations which the Health Board accepted:
Within 1 month
a) Apologise to Mrs B and Mrs C for the failings identified in this report.
b) Offer Mrs B financial redress in the sum of £4,500 reflecting the serious failings I have found and the resulting and lasting significant impact upon her. To further offer Mrs B redress of £300 for the time and trouble she has been put to in pursuing her complaint.
c) Remind the clinicians involved in Mrs B’s care of the importance of reviewing preceding clinical letters, especially where a patient has been lost to follow-up, and of making prompt referrals for patients that require specialist care.
d) Remind the Speciality Doctor of the importance of keeping sufficiently detailed patient records and clinic letters.
e) Review policies relating to the management of outpatient clinic appointments to ensure that the patients with greatest clinical needs are prioritised, particularly when clinics are wholly or partially cancelled.