The complaint
The Ombudsman launched an investigation after Mr L complained about the care and treatment he received from Betsi Cadwaladr University 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 restrict 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.
What the Ombudsman found
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 a 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. Mr L was seen at hospital again in March, and there was a further failure then to properly investigate the cause of his ongoing symptoms.
It was not until September 2018 that an 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 small temporary strokes during the scan , and in the weeks that followed. Damage to the eye and loss of vision because of reduced blood flow were identified from the scan in September, which called for urgent surgical treatment.
Mr L eventually underwent surgery on 8 November.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.
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, 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 that events such as in this case might in future be avoided.”
The Ombudsman’s recommendations
The Ombudsman recommended that Betsi Cadwaladr University Health Board should apologise to Mr L and pay him £4750 for the failings she identified 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.