Mr L complained about the care and treatment he received from Betsi Cadwaladr University Health Board (“the Health Board”) after he attended the Emergency Department on the advice of his optician.

Complaint 1

Mr L complained that the Health Board failed to, between January and September 2018, promptly and appropriately identify, investigate and treat his carotid artery stenosis (blockage of blood vessels in the neck, restricting the blood flow to the middle of the brain, face and head). The Ombudsman found that the Health Board missed opportunities to consider the possibility of carotid artery stenosis or that Mr L may have suffered a watershed stroke (this occurs when the blood supply to an area is compromised within 2 major vessel systems at the same time).

Consequently, the Health Board failed to carry out carotid artery imaging in January and March 2018. The Ombudsman considered that these missed opportunities amounted to service failures and that they caused injustice to Mr L because he continued to experience debilitating symptoms.

The Ombudsman upheld Mr L’s complaint.

Complaint 2

Mr L was further concerned that the Health Board failed to provide him with timely care once the stenosis had been identified in September, up to his surgery in November 2018. The Ombudsman identified that the Health Board delayed treating Mr L’s carotid artery stenosis and ocular ischemic syndrome (damage to the eye and loss of vision as a result of reduced blood flow), despite him suffering transient ischaemic attacks (“TIA” – temporary disruption to a blood supply in the brain) during and following the imaging.

The Ombudsman noted similar failings in a previous case she investigated against the Health Board that identified shortcomings in neurological assessment to diagnose a TIA. Since that investigation, 2 reports (1 external) were published that were extremely critical of vascular care and treatment at the Health Board. They contained significant recommendations for improvements in most areas.

It is the Ombudsman’s view that serious failings occurred in this complaint, including a complete failure to follow both the original Guideline and the Health Board’s own Policy. Mr L now has permanent sight loss and will need life-long treatment to try to manage his ongoing pain, inflammation, and increased pressure as a result of the damage caused to his eye. This constitutes a significant and ongoing injustice. The Ombudsman upheld Mr L’s complaint.

Ombudsman’s recommendations

The Ombudsman made several recommendations, which the Health Board accepted:

  • Provide a meaningful written apology to Mr L for the failings identified in this report.
  • Pay Mr L £4750 redress for the failings identified and the resulting impact upon him, and for the significant time and trouble he was put to in pursuing his complaint.
  • Remind all relevant staff of the requirement for all patients who maybe appropriate for surgery to undergo carotid imaging, in line with the new Guideline.
  • Remind all relevant staff of the clinical indications of a watershedstroke (or TIA) and of the importance of considering this possibility when reviewing patients.
  • The treating Consultant to reflect 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.