Prince Charles Hospital, Merthyr, criticised over leg amputation
Poor care at a hospital may have contributed to a woman having to have her lower leg amputated after she fell into a pond, a report has found.
Staff at Prince Charles Hospital in Merthyr did not do enough to treat an infection after the fall, said public services ombudsman Peter Tyndall.
He said if she had received better care she may not have needed the amputation.
Cwm Taf Health Board accepted all his recommendations, and was ordered to apologise and pay the woman £3,000.
The ombudsman upheld the complaint by the patient, who was called Mrs B in the report.
She fell into her garden pond in July and broke her ankle on a rock at the bottom. Her leg was submerged for about 10 minutes before she was able to haul herself out of the pond and crawl back to her house.
She was taken to Prince Charles hospital where her fracture was assessed and treated.
But Mrs B complained to the ombudsman because she felt she should have been referred to a specialist centre immediately due to the risk of "marine contamination" from the wound being in pond water.
She said the hospital did not send her for specialist care at Morriston Hospital, Swansea, until 11 days after her injury, by which time the infection had taken hold.
Staff at Morriston deemed the infected wound to be so bad that they had to amputate her lower right leg.
"Mrs B suffered a horrific injury and a traumatic period of recovery, ending in a damaging life changing procedure," Mr Tyndall said in his report.
"Although Mrs B's injury presented challenges to the hospital, I find that the care provided fell short of an acceptable standard.
"Furthermore, the failings might have contributed to the sad outcome."
The ombudsman said the hospital should have sought microbiological advice about the woman's injury and that she should have been transferred to Morriston as soon as the infection became apparent.
"Mrs B will have to live with her disability for the rest of her life," he added.
"Moreover, she will have to cope with the uncertainty about whether it could have been prevented. That is a major injustice."
Mr Tyndall said that Cwm Taf had accepted all his recommendations to improve its care of patients.
They include staff from Prince Charles Hospital liaising with those from Morriston to be clearer about when to refer patients for specialist care.