Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

Following the publication of new clinical guidelines in February 20181, Mrs A complained that Cwm Taf Morgannwg University Health Board (“the Commissioning Health Board”) and Swansea Bay University Health Board (“the Providing Health Board”) failed to advise her that she was at an increased risk of damage to her eyesight from the hydroxychloroquine (“HCQ” – a medicine used to treat inflammatory disorders of the joints and skin) she was taking, and to arrange the recommended annual monitoring of her eyes. Mrs A was diagnosed with HCQ retinopathy in February 2020 (a condition where permanent loss of vision is caused by the harmful effects of HCQ on the retina) which she said could have been prevented.
The investigation found that, although Mrs A’s prescription for HCQ had been initiated by a Rheumatologist, Mrs A was discharged from the Rheumatology Department (managed by the Providing Health Board on behalf of the Commissioning Health Board) in 2013, and the prescriber of the HCQ at the time of these events was her GP. However, the decision to discharge Mrs A in 2013 was found to be medically inappropriate and there were failures by the Rheumatology Department to provide a clear handover of care to the GP, and to put in place a shared care agreement to support safe prescribing practice by the GP after that time.
When Mrs A later developed symptoms of blurred vision, the Ophthalmology Department (managed directly by the Commissioning Health Board), failed to undertake the full range of required diagnostic tests for HCQ retinopathy causing diagnostic uncertainty about her symptoms. The Commissioning Health Board also failed to put the recommended eye monitoring service in place more than 3 years after the publication of the
new guidelines. The Ombudsman could not say with any certainty that, even with more timely monitoring, Mrs A would not have suffered the noticeable loss of vision that she did. However, in part, that uncertainty was due to the identified failings in Mrs A’s care, which caused her an injustice.
The Commissioning Health Board also failed to recognise that it had a role in investigating the eye monitoring aspects of Mrs A’s complaint and to provide the GP with the opportunity to contribute to the complaint investigation. Consequently the complaints process failed to fully address the complaint that Mrs A made, and a significant learning opportunity was missed. The Ombudsman’s Pharmacy Adviser highlighted that the new monitoring requirements were not widely communicated in the medical press indicating that Mrs A’s case was unlikely to be an isolated one and that the specialist hospital teams in both Health Boards needed to do more to communicate the new monitoring requirements to their primary care colleagues and to ensure that all patients on HCQ were identified and made aware of the increased risks to their eyesight.
The Ombudsman recommended that each health board should apologise to Mrs A for the failings and make her a payment of £500 in recognition of the uncertainty caused by the failings in her care. Additionally, the specialist teams in both health boards should work collaboratively with pharmacy, medicines management teams and their primary care colleagues to ensure that all prescribers were reminded of their prescribing responsibilities and made aware of the new clinical guidelines and referral pathways. A shared care agreement for the prescribing of HCQ should also be developed and put in place, and any clinical decision support software should be updated to reflect the new clinical guidelines at the point of prescribing.