Hywel Dda Health board pay-out over 'catalogue of errors'
A health board has apologised and is paying £3,250 after a "catalogue of serious errors" involving a woman with a gynaecological condition.
The Public Services Ombudsman for Wales found Emma Turner's care while being treated for endometriosis at Glangwili hospital, Carmarthen was mismanaged.
It found she suffered physical trauma, risk and worry when surgery was abandoned after it had started.
Hywel Dda Health Board accepted the report.
It will pay her £3,250 as an acknowledgement of the injustice she suffered due to the failings, which included an unnecessary operation, and said mistakes had been learnt from.
Miss Turner, 26, had surgery to remove a cyst from her left ovary in June last year but a severe form of endometriosis - a condition that can lead to infertility - was found.
Further surgery was scheduled for September which would be a joint procedure by a consultant gynaecologist and a bowel surgeon.
But after it had begun it had to be stopped because the surgeon was not available and an on-call replacement felt the procedure was so complicated it should be carried out in a specialist department.
Ombudsman Peter Tyndall says doctors should not have gone ahead with the operation in the first place.
Consultants at the hospital then referred Miss Turner, known in the investigation as Miss F, to a hospital under the management of Cardiff and Vale University Health Board for ongoing treatment.
But she said that the referral failed and was left without an appropriate treatment plan. She faced major delays without a clear indication of when she would re-commence treatment.
It found that a complaint made to Hywel Dda Health Board by Miss Turner's mother had to be chased and the response was found to be inadequate.
Miss Turner told BBC Wales she has struggled since her "ordeal" started.
"I have had no social life and most days being a struggle to carry out normal day to day activities," she said.
"Being in constant pain, feeling drained, tired, and even some days a strain to go to work."
She added: "Carrying out rigorous research on the disease I have learned that there is no cure but is the case of managing the symptoms and preventing the endometriosis from returning.
"I hope from this experience that the Hywel Dda Health Board have learned some serious lessons on their mistakes and should learn about the correct pathways of making referrals to higher centres.
"Having gone through this terrible ordeal, I hope that no one else has to go through the same trauma and any case of severe endometriosis is automatically referred to a higher centre."
In his findings, Mr Tyndall upheld the complaint saying: "In short, there was a catalogue of serious errors running through Miss F's medical care at the hospital.
"She was badly prepared for both procedures psychologically and poorly prepared physically for the second operation.
"The arrangements for the second operation were not rigorous and the plans floundered.
"Most importantly, Miss F was subject to an operation that should not have occurred and is having to be repeated at another centre.
"Miss F suffered the worry, risk and physical trauma of an ill-planned, badly prepared and abortive surgical intervention that should not have been arranged in the first place.
"It is also the case that Miss F has incurred three additional months waiting time due to the referral in September 2011 not taking place in June. This represents a serious injustice to her."
He also partially or fully upheld the other aspects of the complaint.
A spokesperson for Hywel Dda health board said: "The health board would like to apologise to the patient for the failures identified in the Ombudsman's report and the distress these caused her.
"We fully accept the findings of the report and have undertaken action to ensure such a situation will not happen again.
"This has included that ensuring a multi disciplinary team meeting takes place prior to all elective joint surgical procedures."