Public interest report: Hywel Dda University Health Board (202403251)

This report is issued under s.23 of the Public Services Ombudsman (Wales) Act 2019.

We have taken steps to protect the identity of the complainant and others, as far as possible.  The name of the complainant and others has been changed as well.

Mrs C complained about whether the standard of care provided to her mother, Mrs B, for the management of her cataract (when the lens in the eye develops a cloudy patch) to her right eye was clinically appropriate and timely.

The investigation found that Hywel Dda University Health Board (“the Health Board”) did not respond appropriately to advice it requested from a Second Health Board regarding Mrs B’s care.  During the COVID_‑19 pandemic when public health measures which were put in place to prevent the spread of infection I have seen no evidence that the Health Board considered guidance in place at the time to assess the risk this would cause to Mrs B.  When Mrs B was seen again, following the easing of these measures, the review she underwent was inadequate.  Relevant tests were not undertaken, a letter to her GP regarding medication was insufficiently detailed and an opportunity was missed to make an earlier referral for further treatment.  During the period of time under investigation Mrs B experienced numerous cancelled clinic appointments.

These are significant service failings.  Mrs B, who is blind in her left eye, is now also significantly sight impaired in her right eye.  Mrs C has described the devastating impact this has had on both Mrs B and her wider family.  I also consider that the failures in this case are ones from which other health boards can learn.  I have seen no evidence the Health Board assessed the potential harm to Mrs B when cancelling clinic appointments.  Earlier opportunities to identify the seriousness of Mrs B’s condition, and to refer her for further treatment, were also missed.

The Ombudsman made a number of recommendations which the Health Board accepted:

Within 1 month:

a) Apologise to Mrs B and Mrs C for the failings identified in this report.

b) Offer Mrs B financial redress in the sum of £4,500 reflecting the serious failings I have found and the resulting and lasting significant impact upon her. To further offer Mrs B redress of £300 for the time and trouble she has been put to in pursuing her complaint.

c) Remind the clinicians involved in Mrs B’s care of the importance of reviewing preceding clinical letters, especially where a patient has been lost to follow-up, and of making prompt referrals for patients that require specialist care.

d) Remind the Speciality Doctor of the importance of keeping sufficiently detailed patient records and clinic letters.

e) Review policies relating to the management of outpatient clinic appointments to ensure that the patients with greatest clinical needs are prioritised, particularly when clinics are wholly or partially cancelled.

1. Mrs C complained about whether the standard of care provided to her mother, Mrs B, for the management of her cataract (when the lens in the eye develops a cloudy patch) was clinically appropriate and timely.

2. I obtained comments and copies of relevant documents from Hywel Dda University Health Board (“the Health Board”) and considered those in conjunction with the evidence provided by Mrs B. I also obtained professional advice from 1 of my professional advisers, a Consultant Ophthalmic Surgeon.  The Adviser was asked to consider whether, without the benefit of hindsight, the care or treatment had been appropriate in the situation complained about.  I determine whether the standard of care was appropriate by making reference to relevant national standards or regulatory, professional or statutory guidance which applied at the time of the events complained about.  I have not included every detail investigated in this report, but I am satisfied that nothing of significance has been overlooked.

3. Both Mrs C and the Health Board were given the opportunity to see and comment on a draft of this report before the final version was issued.

4. Prioritisation of ophthalmic procedures guidance document, Royal College of Ophthalmologists, May 2020 (“the Prioritisation Guidance”). This guidance was developed during the COVID-19 pandemic to aid ophthalmic services in the prioritisation of surgical procedures.  Cataract surgery for angle closure glaucoma, where imminently sight threatening, is listed as a procedure that should be carried out within 4 weeks, as deferment presents a high risk of harm to the patient.

5. Management of Ophthalmology Services during the COVID pandemic, Royal College of Ophthalmologists (“the Management Guidance”). This states that the risk of patients acquiring COVID-19 during an ophthalmology appointment must be weighed against their risk of coming to harm by failing to treat eye disease.  Ophthalmology services for conditions which are imminently threatening to sight, eye integrity or life threatening are listed as those which “MUST CONTINUE” especially if the only/better seeing eye is affected.

6. On 25 June 2012 a Consultant Ophthalmologist (“the Consultant Ophthalmologist”) from the Health Board wrote to a Consultant Ophthalmic Surgeon (“the Ophthalmic Surgeon”) from another health board (“the Second Health Board”) regarding Mrs B. He detailed Mrs B’s current condition and treatment and wrote that “I would be grateful for your advice on her future management”.

7. On 30 August, having reviewed Mrs B, the Ophthalmic Surgeon wrote to the Consultant Ophthalmologist with his findings. These included a diagnosis of right eye early primary angle closure (a condition which causes narrowing of the fluid drainage passages of the eye and effects how fluid escapes from the eye.  This can cause pressure to rise in the eye and may result in permanent damage to vision).  In respect of treatment, he wrote that Mrs B “needs right YAG laser peripheral iridotomy in the near future”.  A YAG laser peripheral iridotomy (“YAG PI”) involves the creation of a small hole in the iris to help treat raised pressure in the eye.  This was followed by a further letter dated 15 October detailing treatment Mrs B had undergone which stated that “At some stage she may well benefit from a right lens extraction/YAG laser peripheral iridotomy”.

8. Mrs B was eventually discharged from the care of the Second Health Board in July 2015. During this time she only received treatment for cysts on her eyelids.

9. Mrs B attended appointments arranged by the Health Board throughout 2019. During this time her left eye was predominantly monitored and checked due to a previous history of complications following treatment for glaucoma (increased pressure in the eye causing damage to the nerve that connects the eye to the brain) in 2012.

10. On 20 January 2020, Mrs B was reviewed by an Associate Specialist in Ophthalmology. It was noted that she was blind in her left eye and had some degree of cataract in her right eye.  Mrs B was advised to continue lubricant drops and a plan was made for her to be reviewed in 3 months, or sooner if needed.

11. On 10 June 2021, the Health Board received a referral from Mrs B’s optician as they had noted she had a dense nuclear sclerotic cataract (where the lens of the eye hardens and becomes cloudy) in her right eye. The referral included a form completed by Mrs B indicating that she would be willing to consider surgery.  On 14 July an “Eye Care Services New Referrals Grading” Sheet was completed.  This noted that Mrs B should be seen in clinic within 12 weeks and set a target date of 25 September.

12. The Health Board cancelled appointments in November and December and Mrs B was next seen on 3 March 2022 by a Speciality Doctor in Ophthalmology (“the Speciality Doctor”). She was identified as having primary open angle glaucoma in her right eye.  A plan was made to postpone cataract surgery in order to treat Mrs B’s raised eye pressure, and she was prescribed eye drops.

13. The Health Board cancelled a further appointment in March. Mrs B was next seen on 20 April.  She was recorded as displaying signs of a significant cataract in her right eye.

14. Appointments in June and August were cancelled by the Health Board. Mrs B was next seen on 6 October when she was listed for urgent right cataract surgery.  She underwent a pre-operative assessment on 1 November where she was classed as fit for surgery to go ahead.

15. Mrs B was next seen on 8 February 2023. At this appointment it was recorded that Mrs B had stopped using the eye drops that had been prescribed by the Speciality Doctor in March 2022.  Mrs B was instructed to restart the drops.  During that appointment it was noted that Mrs B’s vision was now “quite bad” in her right eye.  Following that appointment the clinician that had seen Mrs B contacted a waiting list coordinator and asked that it be arranged for Mrs B to undergo cataract surgery within the next 2 months.

16. By 8 March, when Mrs B was next seen, the pressure in her right eye had shown improvement, and Mrs B was prescribed additional eye drops in order to bring the pressure down further. Mrs B subsequently had cataract surgery to her right eye on 24 March.

17. On 12 April, an appointment was cancelled by the Health Board. On 20 April Mrs B was reviewed following her cataract surgery.  Her right eye was recorded as settling well and that she was continuing to use anti-glaucoma eye drops.

18. When Mrs B was next seen on 8 June she reported that the sight in her right eye had deteriorated and that her optician had informed her that she had advanced optic nerve damage to her right eye. Following this appointment, Mrs B was certified as severely sight impaired and referred to another consultant ophthalmologist (“the Consultant Ophthalmologist”).  This letter was copied to Mrs B’s optician and GP, with the GP being asked to continue a prescription of eye drops and to arrange social and psychological support for Mrs B who had reported feeling depressed at her further loss of vision.

19. Mrs B’s daughter, Mrs C, complained to the Health Board on her mother’s behalf on 9 August. Mrs C said that her mother had waited 2 years for cataract surgery, during which time her optic nerve had become severely damaged.  Mrs C said that numerous appointments had been cancelled, despite her mother now being almost blind.

20. The Health Board responded to Mrs C’s complaint on 1 May 2024. It said that there had been delays in providing clinic appointments in 2020 and 2021 due to pressures caused by the COVID-19 pandemic, but that Mrs B was seen regularly during 2022 and 2023.  It said that Mrs B did not use eye drops between November 2022 and February 2023 which likely contributed to additional damage to the optic nerve.  It said that the outcome of cataract surgery on a patient with glaucoma is usually not as good as those in a patient without glaucoma.

21. Mrs C complained to the Ombudsman in July. Mrs C said 11 appointments were cancelled by the Health Board during the time her mother was waiting for surgery.  She said that had these appointments gone ahead the deterioration in her mother’s optic nerve may have been picked up, and cataract surgery performed earlier.  Mrs C said that her mother had always used eye drops as prescribed, but that these drops were not always prescribed consistently by the Health Board, which sought to blame her mother for periods where they were not used.  Mrs C said her mother’s eye pressure was not checked during her pre‑operative assessment or on the morning of the cataract surgery.  She said that her mother was told she had optic nerve damage during the appointment in April, but that this was not recorded in her medical records.  Mrs C said that her mother underwent further procedures to try and preserve the sight in her right eye in June and July 2024 but that these had been unsuccessful.  She said that her mother was told by a consultant in July that she had been referred to them too late.

22. As her mother had already lost the sight in her left eye, Mrs C said that the deterioration in her right eye has resulted in her losing her confidence and independence, and becoming depressed and isolated. She said that her mother now needed assistance with most aspects of daily living and receives care to allow her to live at home.  This was very distressing for both her and her family.

23. The Health Board said that Mrs B was not followed up within 3 months of the January 2020 appointment due to COVID-19 restrictions as all elective work was postponed.

24. In relation to surgery, the Health Board said that this was first discussed with Mrs B in April 2022, who said that she would think about whether to have the surgery. When Mrs B was next seen in October 2022 she was listed for surgery.  This surgery subsequently took place in March 2023, which was within the expected timeframe for cataract surgery.

25. Post-surgery, the Health Board said that Mrs B and Mrs C were given discharge advice. It said that patients with uncomplicated cataract surgery were usually discharged but Mrs B was kept in the system due to her other eye conditions.  She was followed up within 4 weeks, and at this appointment it was noted that Mrs B’s eye was settling well.

26. In commenting on a draft of this report, the Health Board said that it did not consider the letters from the Ophthalmic Surgeon in August and October 2012 to be a referral for treatment. Rather it considered them to be for information purposes only.  It said that the letter of 30 August was not in Mrs B’s notes but that the letter of 15 October had been reviewed and annotated by a doctor who had indicated that it was for filing only.

27. The Adviser said that the Health Board did not take appropriate action following the letter of August 2012 from the Ophthalmic Surgeon. As such Mrs B was “lost to follow-up” meaning that she was not receiving intended continuing care.  They said that when Mrs B was seen in 2019 her previous records should have been checked and reviewed.  This was of particular importance given Mrs B’s past medical history with her left eye.  The Adviser said that a YAG PI should have been done in Mrs B’s right eye as soon as possible as by that point 7 years had elapsed since the recommendation was made.

28. The Adviser said that YAG PI is a temporary measure to treat angle closure in the presence of a cataract. Cataract extraction is recognised as a crucial treatment for this condition as, if the cataract is left to grow, it can cause damage to the optic nerve.

29. The Adviser was unable to identify any evidence that Mrs B had undergone visual field tests or Optical Coherence Tomography Scans of the optic nerve (“OCT scans” – where light is used to create a picture of the back of the eye) from 2019 onwards, even when it was evident in 2022 that Mrs B had glaucomatous changes. Had these been carried out, the Adviser’s opinion was that a trend of deterioration would have been evidenced that should have prompted more urgent treatment.

30. Concerning the finding by the Specialty Doctor on 8 March 2022 that Mrs B had primary open angle glaucoma, the Adviser said that this was not clinically backed up by any documentation in the notes such as an evaluation of Mrs B’s anterior chamber depth (“ACD” – the space between the iris and the front most part of the eye). The Adviser said that, had Mrs B’s ACDs been checked, it would have been obvious that they were progressively narrowing, and therefore cataract surgery should have been performed without delay.

31. Whilst the Specialty Doctor sent a letter to Mrs B’s GP informing them that Mrs B had been prescribed eye drops, it contained no specific instructions as to the dose or duration, or whether it should be continued as a repeat prescription. This letter was not copied to Mrs B.  The Adviser said that when a new medication is commenced a clinic letter should be copied to the person who made the referral, the patient and their GP.  This letter should detail the dose, frequency and duration of the medication as well as who to contact if the patient encounters any problems in using or obtaining the medication.  The Adviser added that not using eye drops potentially caused further rises in the pressure within Mrs B’s right eye and as a result deterioration of her optic nerve.

32. Whilst the COVID-19 restrictions did cause unavoidable delays, the Adviser referred to the Management Guidance and the Prioritisation Guidance (see paragraphs 4 and 5). As Mrs B had already lost the sight in her left eye, her clinical appointments, reviews and treatment should have continued during this time, either face-to-face in clinic or virtually by arranging regular review of Mrs B by her optician who would share their findings with the hospital clinicians.  Had this happened the Adviser was of the view that the deterioration in her sight and the thinning of her optic nerve would have been evident.  This would have necessitated cataract surgery as a matter of urgency, which should have taken place within 4 weeks according to the guidance.

33. When Mrs B did undergo surgery the Adviser could find no evidence that her eye pressure was checked in advance. The Adviser said that this check was not routine but it was good practice for glaucoma patients to have their eye pressure checked on the day of surgery.  This provides a crucial baseline to assess any changes after surgery.  The Adviser said that it was difficult to establish the likely impact of the check not being carried out.  They said that Mrs B’s operation was longer than usual for cataract surgery, but that no complications were documented.  When Mrs B’s eye pressure had last been checked – 10 days prior to surgery – it had reduced and was not at a level where surgery would not be recommended.

34. The Adviser said that the clinic on 12 April 2023 was only partially cancelled and that Mrs B should have been seen on this date. As a glaucoma patient Mrs B was at higher risk of postoperative spikes in her eye pressure, which could lead to further optic nerve damage.  Mrs B’s next outpatient appointment was on 8 June.  The Adviser said it was correct to refer Mrs B to the Consultant Ophthalmologist.  However, they also said that this should have been done much sooner, and certainly after Mrs B’s review in March 2022.

35. The Adviser noted deficiencies in the Electronic Patient Record system (“the EPR system” – a computer based system for storing the medical history of patients). At present the EPR system does not highlight patients with a sight threatening disease that must be seen in clinic or who are due for follow-up.  Without this information the Adviser said that there was a risk patients would continue to be lost to follow-up, as was the case with Mrs B.

36. The Adviser concluded that Mrs B had not received appropriate care and treatment. If she had, Mrs B would likely have retained useful vision in her right eye.

37. The Health Board did not act in a timely manner following the advice from the Ophthalmic Surgeon in August and October 2012. The Health Board has said that it does not consider the letters as referrals for treatment but it is clear that these letters arose because the Health Board sought advice from the Second Health Board on treatment for Mrs B.  As such the onus was on the Health Board to ensure that Mrs B received that treatment.  7 years elapsed before Mrs B was seen again by the Health Board, but I have seen no evidence that her records were reviewed at this point, or that any action was taken to establish if the YAG PI recommended in 2012 had been carried out.

38. The COVID-19 pandemic and the public health measures which were put in place to prevent the spread of infection made it harder to provide treatment for non-COVID-19 related conditions. During times of peak infection and hospital admissions, staff resources were severely stretched to such an extent that treatments for other non-COVID conditions were suspended for significant periods of time.  My investigation carefully considered this context and took into account both the Management Guidance and the Prioritisation Guidance, which were applicable at the time.

39. In January 2020 it was documented that Mrs B was blind in her left eye, in addition to having a cataract in her right eye. The Health Board has said that there was a delay in Mrs B receiving further treatment because the COVID-19 pandemic meant all elective work was postponed.  The Management Guidance states that the risk to patients in respect of COVID-19 should be weighed against the risk to their sight.  I have seen no evidence that such an assessment was made in Mrs B’s case.

40. Despite receiving a referral from Mrs B’s optician, it was over 2 years before she was seen again in March 2022. Had Mrs B been seen during this time, and appropriate tests carried out, the Adviser was of the view that the deterioration in Mrs B’s sight would have been evident.  This would have identified that surgery should have been carried out within 4 weeks, in line with the Prioritisation Guidance.

41. The Adviser has raised serious concerns about the review that Mrs B underwent in March 2022. Relevant tests were not undertaken, the letter to Mrs B’s GP regarding eye drops was insufficiently detailed and an opportunity was missed to make an earlier referral to the Consultant Ophthalmologist.

42. Mrs C said that she felt that her mother was blamed for not continuing eye drops prescribed by the Speciality Doctor. There is no evidence that either Mrs B nor her GP were made aware of the need to continue the eye drops, and by the time she was reviewed in February 2023 her eye pressure had risen significantly.  The Adviser has said this could cause further deterioration of Mrs B’s optic nerve.

43. These are significant service failures. The Adviser has said that had they not occurred Mrs B, who is blind in her left eye, would likely have retained useful vision in her right eye.  Instead, she is now significantly sight impaired.  Mrs C has described the devastating impact this has had on Mrs B and her family.  As such Mrs C’s complaint is upheld.

44. I also consider that the failures in this case are ones from which other health boards can learn. I have seen no evidence the Health Board assessed the potential harm to Mrs B when cancelling clinic appointments.  Earlier opportunities to identify the seriousness of Mrs B’s condition, and to refer her for further treatment, were also missed.

45. In respect of the Advisers concerns regarding the EPR system this is potentially a national issue as the system is used by other health boards in Wales. As such the final report will be shared with the Welsh Government and this concern highlighted for its consideration.

46. I recommend that within 1 month of the date of the final report the Health Board:

a) Apologise to Mrs B and Mrs C for the failings identified in this report.

b) Offer Mrs B financial redress in the sum of £4,500 reflecting the serious failings I have found and the resulting and lasting significant impact upon her. To further offer Mrs B redress of £300 for the time and trouble she has been put to in pursuing her complaint.

c) Remind the clinicians involved in Mrs B’s care of the importance of reviewing preceding clinical letters, especially where a patient has been lost to follow up, and of making prompt referrals for patients that require specialist care.

d) Remind the Speciality Doctor of the importance of keeping sufficiently detailed patient records and clinic letters.

e) Review policies relating to the management of outpatient clinic appointments to ensure that the patients with greatest clinical needs are prioritised, particularly when clinics are wholly or partially cancelled.

47. I am pleased to note that in commenting on the draft of this report the Health Board has agreed to implement these recommendations.

25 February 2026

Michelle Morris

Ombwdsmon Gwasanaethau Cyhoeddus | Public Services Ombudsman