Posted: Thu 2nd Nov 2023

Patient suffers permanent sight loss due to failings by North Wales health board, Ombudsman finds

News and Info from Deeside, Flintshire, North Wales
This article is old - Published: Thursday, Nov 2nd, 2023

A patient in the care of Betsi Cadwaladr University Health Board has suffered permanent sight loss and will need life-long treatment as a result of inadequate vascular services, according to latest report by the Public Services Ombudsman for Wales. ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

The Ombudsman launched an investigation after Mr L complained about the care and treatment he had received from the North Wales health board in 2018. ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

Mr L complained that between January and September the health board failed to promptly and appropriately identify, investigate and treat a blockage of blood vessels in his neck (a condition called carotid artery stenosis, where the blockage restricts the blood flow to the middle of the brain, face and head). ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

He also complained that the Health Board did not provide him with timely care once the blockage had been identified in September, up to his surgery in November 2018. ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

Ombudsman Investigation ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

The Ombudsman found that when Mr L attended the Emergency Department in January 2018, the Health Board missed opportunities to consider the possibility that he suffered watershed stroke (which occurs when the blood supply to an area is compromised within 2 major vessel systems at the same time). ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

The Ombudsman concluded that had Mr L undergone appropriate scan in January, he would have likely been offered surgery as a matter of urgency. ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

Despite Mr L’s ongoing symptoms, it was not until September 2018 that appropriate scan was arranged, revealing the issue. ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

The Ombudsman also found that the health board delayed treating the blockage following the diagnosis. This was even though Mr L suffered temporary strokes during and following the imaging. ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

He was also diagnosed with damage to the eye and loss of vision because of reduced blood flow, which called for urgent surgical treatment. ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

Mr L’s eventually underwent surgery on 8 November. ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

However 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. ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

Recommendations ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

The Ombudsman recommended that Betsi Cadwaladr University Health Board should apologise to Mr L and pay him £4750 for the failings identified in the report and the impact upon him. ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

In addition, the Ombudsman recommended that the Health Board 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.

Commenting on the report, 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, two 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 that events such as in this case might in future be avoided.” ‌​‌‌​​​‌‍‌​‌​‌‌‌​‍‌​‌​‌‌​​‍‌​​‌‌‌‌​‍‌​​​​‌‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌‌​‌​‍‌​​​​‌‌​‍‌​‌‌‌‌‌​‍‌​​​‌‌​‌‍‌​​‌‌​‌​‍‌​‌​‌​‌‌‍‌​​‌​‌‌‌‍‌​​‌​‌‌​‍‌​​‌‌​‌​‍‌​​​‌​​‌‍‌​​‌‌​‌​‍‌​​​‌‌​​

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