Public Services Ombudsman report - 11/3/26
11 March 2026
The Public Services Ombudsman for Wales has investigated a complaint and found service failure by Hywel Dda University Health Board.
A report on the results of the Ombudsman’s investigation has been sent to the Health Board.
The complaint related to failures in the Ophthalmology service.
A copy of the report is available on our website and for inspection by the public, without charge, during normal office hours at Corporate Offices, Hywel Dda University Health Board, Second Floor, Block C, Government Buildings, Picton Terrace, Carmarthen, SA31 3BT, for a period of three weeks from Wednesday, 11 March 2026.
Anyone who wishes to do so may take a copy of this report or extracts from it.
Sharon Daniel, Director of Nursing, Quality and Patient Experience at Hywel Dda University Health Board said:
“We acknowledge the findings of the Ombudsman’s report and we are sorry for the failings identified and the impact on the patient who was under our care and her family."
“We recognise that there were significant failures in the way we approached the treatment of our patient that led to her suffering significant sight impairment. We apologise unreservedly for these failures.
“This is not the level of service we wish to provide our patients and we will strive to do better. We accept the Ombudsman’s recommendations and have started working on ways we can improve.”
Improvements include increased staffing levels and the establishment of a glaucoma co-ordinator role.
The service has also introduced a glaucoma stratification process – a systematic approach to categorising patients based on their risk of significant vision loss. This process is crucial for deciding the appropriate care pathways and resource allocation.
The introduction of the Wales General Ophthalmic Services (WGOS) 4 pathway for glaucoma has established highly trained glaucoma optometrists in the community which means that suitable glaucoma patients are discharged for care closer to their homes.
The ophthalmology service is moving towards installing Open Eyes, an electronic patient record system that will support an improvement in record keeping.
The glaucoma module currently in its test phase but is expected to be available soon. This module will include a standardised letter templates with mandatory data fields such as eye pressures.
This, in turn, will improve quality and consistency of the letters and will be compatible with Swansea Bay University Health Board records, ensuring seamless information sharing for future patients.
The regional work continues in ophthalmology, through the Regional Eye Care Programme Board, which is focusing on glaucoma delivery as a priority.
For further information and for the full Ombudsman’s report, please follow the link: https://hduhb.nhs.wales/Public-interest-reports
ENDS