Betsi Health Board failings led to patient losing eyesight

The Ombudsman launched an investigation after 'Mr L' complained about the care and treatment he received from the North Wales Health Board in 2018.

Mr L complained that between January and September that year 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).

Mr L 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.

Following a review into the treatment, 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).

Had Mr L undergone an 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 eventually underwent surgery on 8 November, but 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 £4,750 for the failings identified in the report and the impact upon him.

There were also recommendations regarding future policies and reviews of patients.

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 acknowledgment of the good progress and significant headway made in vascular services recently, we will continue to provide strong oversight and governance of the specialty.”