Vulnerable Woman Loses Eyesight After Unit Delays
A vulnerable young adult with learning disabilities lost sight in her right eye after staff at a specialist residential learning disability unit failed to monitor her injury properly.
Mrs X (anonymised) made a complaint about the care received by her 24-year-old daughter, Y, (anonymised) at a unit she lived in that was run by Swansea Bay University Health Board in 2018.
Y had diagnoses of Atypical Autism (presenting with some symptoms of autism), Learning Disability – mild to moderate and mental health difficulties. Her key behaviours include verbal and physical aggression, self-injurious behaviour, non-compliance, property destruction, ritualistic behaviours and socially inappropriate behaviours.
Mrs X made a complaint as she was concerned that inadequate eye care was provided to her daughter 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.
Mrs X complained that no one realised the seriousness of Y’s condition and she believed that Y’s eye had been in a state of injury for some six weeks after Y had hit it. Mrs X said she was young to lose her sight in the way she did and she found this heart-breaking and difficult to accept.
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 as she was denied the opportunity of a timely referral and clinical review.
The Ombudsman also stated that he believed Y’s human rights under Article 8 were engaged as The Health Board has not sufficiently demonstrated that it ensured the needs of an adult with a learning disability, such as Y who was unable to effectively articulate her vision problems, were sufficiently respected
The Health Board agreed to implement the Ombudsman’s recommendations within one month. These included providing Mrs X with a written apology for the failings identified and referring the report to the Board, and the Health Board’s Equalities and Human Rights team next Learning Disabilities Service monthly meeting.
Commenting on the report, Nick Bennett, Public Services Ombudsman for Wales, said:
“Individuals in institutional care settings are amongst the most vulnerable in society and public bodies need to be extra vigilant to ensure their needs are met.
“This is an extremely serious case where a young woman has been left with a permanent life-changing injury that may have been avoided.
“I am pleased that the Health Board has agreed to implement my recommendations which I hope will ensure the same mistakes are not repeated. I hope this brings some limited comfort to Mrs X and Y at a quite traumatic time.”