Mrs A complained about care provided to her by Hywel Dda University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”). The Ombudsman investigated the following specific concerns:
a) That the First Health Board failed to liaise appropriately with the Wales Fertility Institute (“the WFI” – which is operated at Neath Port Talbot Hospital by the Second Health Board) to ensure that Mrs A received appropriate fertility care.
b) That the First Health Board failed to explain the potential impact of Mrs A’s hydrosalpinx (where a fallopian tube becomes blocked, which can lead to fertility problems) to Mrs A or her GP in a timely manner.
c) That before providing cycles of in vitro fertilisation (“IVF” – where an egg is removed from the woman’s ovaries and fertilised with sperm in a laboratory) treatment to Mrs A in 2016 and 2020 the Second Health Board failed to carry out appropriate additional screening, taking into account her medical history.
The Ombudsman found that the First Health Board missed opportunities in 2016 and 2018 to inform the WFI about Mrs A’s history of hydrosalpinx. This was caused by a series of communication failures, and an apparent failure to consider the significance of the condition. The First Health Board failed to offer Mrs A surgery to treat the condition and improve her chances of conceiving through IVF. As a result of this, the IVF treatment Mrs A received was compromised. The First Health Board also failed to explain the significance and potential impact of the hydrosalpinx to Mrs A or her GP. Complaints a) and b) were upheld.
The Ombudsman found the Second Health Board, through the WFI, failed to request a copy of a scan report mentioned in the 2016 IVF referral. This was a missed opportunity to ensure that Mrs A’s history of hydrosalpinx was considered and addressed prior to starting IVF. Complaint c) was also upheld. As a result of the failings identified, the IVF treatment Mrs A underwent was compromised.
The Health Boards agreed to the Ombudsman’s recommendations, including for both Health Boards to apologise to Mr and Mrs A and review how they handled Mrs A’s complaint. The First Health Board agreed to further recommendations including offering Mr and Mrs A financial redress in the sum of £1950, and reviewing how it shares clinical information with the WFI.