Mrs X was concerned that inadequate eye care was provided to her
daughter (“Y”) in light of her known self-injurious behaviour (which included hitting herself on the head and face which were known to cause bruising). As a result, Mrs X was concerned that Y’s eye injury was not diagnosed sooner. Y has a diagnosis of Atypical Autism, Learning Disability – mild to moderate and mental health difficulties and was, at the time of the events complained about, living in a specialist residential learning disability unit (“the Unit”) run by the Health Board.

The Ombudsman found that while Y received good care in terms of planning and delivery to meet her specialised learning disability needs, there were serious shortcomings in the care Y received in June 2018 relating to her eye management. While staff noted concerns in relation to Y’s right eye, which required monitoring, there was no evidence that monitoring took place or that these concerns were escalated to clinical staff. When concerns were raised in September about Y’s eye, an urgent review was requested and she was taken to the Emergency Eye Unit at a hospital in the area of another health board where she was diagnosed with total retinal detachment and traumatic cataract of the right eye (a cataract is when the lens inside the eye develops cloudy patches).

While it was possible that Y’s retinal detachment occurred in June 2018, the Ombudsman was unable to say with any certainty that earlier referral for ophthalmology advice would have resulted in a different outcome for Y. That said, the failure to monitor Y’s eye or refer for specialist advice at that time was a service failure; Y did not receive an appropriate level of eye care which was not in line with the requirement to provide Fundamentals of care. This caused Y, a vulnerable young adult, an injustice as she was denied the opportunity of a timely referral and clinical review. It was also a considerable injustice to Mrs X as there will always be an element of doubt about whether the outcome could have been different for Y who ultimately lost sight in her right eye.

The Ombudsman also found that communication with Mrs X about Y’s eye condition was inadequate and she was not kept updated. This was a serious communication failing as the news of Y’s eye condition came as a shock to Mrs X and caused her alarm and distress which was an injustice to her. The Ombudsman upheld Mrs X’s complaint.

The Ombudsman cannot determine if the action / inaction of a body within his jurisdiction amounts to a breach of human rights. However, he can comment more broadly on whether the Human Rights Act 1998 is engaged. The Ombudsman recognises that individuals in institutional care settings are amongst the most vulnerable in society and so are amongst the most vulnerable to having their human rights compromised. He found that the failings in Y’s care engaged her Article 8 rights (a right to respect for one’s private and family life) as the Health Board had not sufficiently demonstrated that it had ensured that the needs of an adult with learning disability, such as Y, were sufficiently respected.

The Health Board agreed to the Ombudsman’s recommendations that, within 1 month of the date of his report, it should:

a) Provide Mrs X with a written apology for the failings identified.

The Health Board agreed to the Ombudsman’s recommendations that, within 3 months of the date of his report, it should:

b) Refer the report to the Board, and the Health Board’s Equalities and Human Rights team to identify:

i) how consideration of human rights can be further embedded into clinical practice

ii) relevant human rights training for Registered Nurses on the Unit (and across the Health Board).

c) Arrange for a copy of this report to be shared and discussed at the next Learning Disabilities Service monthly meeting using this case as a learning event to consider:

iii) adopting the SeeAbility (a charity that provides specialist support, accommodation and eye care help for people with learning disabilities, autism and sight loss) functional vision assessment tool as part of a patient’s annual review or in an acute or new scenario

iv) arranging training for staff on the Unit from the Health Board’s Ophthalmology Department on the importance of identifying and escalating any concerns relating to possible eye injuries

v) a mechanism for ensuring that patients are accessing regular eye tests / eye health checks in line with the National Autistic Society (“NAS”) and SeeAbility advice, and the Learning Disability Annual Health Check (part of the 1000 Lives Improvement, the national improvement services for the NHS in Wales) and NICE Pathways “Learning disabilities and behaviour that challenges overview”

vi) arranging training for Registered Nurses on the Unit to take into account relevant advice, such as the NAS and SeeAbility advice, to inform them of the importance of good eye care for learning disabled and autistic patients, especially where those patients’ behaviour includes self-injurious behaviour.

d) Arrange for a copy of this report to be shared and discussed with members of the medical and nursing team involved in Y’s care using this case as a learning event to highlight the importance of / remind them:

vii) to follow the Nursing and Midwifery Council’s Code around providing fundamental of cares to patients’ physical healthcare needs, which includes eye care

viii) to remind the team of the importance of being open and transparent with relatives of patients in reporting patients’ injuries and serious incidents to their family

ix) to ensure that the clinical practice of monitoring a patient’s physical condition is evidence-based and consistent and that concerns are escalated without delay to senior clinical staff for appropriate action.

e) Provide documentary evidence to show that the recommendations have been carried out within the stipulated timescales.