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Clinical treatment in hospital: Cwm Taf Morgannwg University Health Board

Report date

24/10/2023

Subject

Clinical treatment in hospital

Outcome

Not Upheld

Case ref number

202106645

Report type

Non-public interest report issued: complaint not upheld

Relevant body

Cwm Taf Morgannwg University Health Board

The Ombudsman investigated a complaint from Mrs A about the eye care provided to her son B, between July 2019 and June 2021 by the Health Board. The investigation focused specifically on whether the decision to discharge B in May 2020 (from the eye clinic) was appropriate, and whether there was a failure to identify that B was developing Coates Disease (this primarily involves abnormal blood vessels and fluid accumulation in the retina which can lead to vision problems) before June 2021.
The Ombudsman found that the decision to discharge B in May 2020 was appropriate given that there was an absence of new symptoms or concerns. This complaint was not upheld. However, the Ombudsman invited the Health Board to review its decision not to send a discharge letter, and to review its explanation about the reason for the delayed follow-up appointment.
The Ombudsman found that there was no failure to identify that B was developing Coates Disease. During an appointment in July 2019, B did not show symptoms suggestive of Coates Disease. He presented with pupil asymmetry which is not typically a primary sign of Coates Disease. When B was followed up, there were no reported new symptoms or concerns. This complaint was not upheld.

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