Cardiff and Vale health board apology ordered after treatment 'failures'
A health board has apologised and been told pay £5,000 to the widow of a stroke victim who died following "systematic failures" in his treatment.
A watchdog said mistakes were also made diagnosing the man, who has not been named.
A report said Cardiff and Vale health board did not act in accordance with national guidelines for the treatment of strokes.
The board has admitted it did not meet "the high standard of care" expected.
The man's widow said her husband might otherwise have survived.
The stroke victim - referred to as Mr T in the report by the acting Public Services Ombudsman for Wales, Prof Margaret Griffiths - was admitted to hospital in April 2011 but died a month later.
Prof Griffiths said it was not possible to say definitely that Mr T would have lived but his "chances of survival were significantly reduced as a result of serious shortcomings in his care".
She said the health board should review its arrangements for patients who may have had an acute stoke.
Prof Griffiths added: "From the information I have seen, the successful treatment of a stroke is reliant upon two key factors - speed and specialist treatment.
"In order to improve the chances of survival and the reduction of life-changing consequences for the patient, it is critical that prompt investigation, diagnosis and treatment by appropriately trained specialists are delivered. I have found that Mr T's care was wanting in each of these respects.
"Whilst there are examples of good care to be found - for example, in respect of the initial treatment of Mr T's presenting symptoms and his care on the stroke rehabilitation unit - there is overwhelming evidence of an abject failure to treat the serious development represented by Mr T's stroke with the requisite urgency and specialist skill."
She said patients who may have had an acute stroke should have a scan within an hour and be admitted immediately to a specialist unit.
Prof Griffiths said the health board should also examine its complaints investigation process.
She ordered the £5,000 payment to Mrs T for the "time and trouble to which she has been put in pursuing this complaint and in recognition of the additional distress caused" to her and her family.
Prof Griffiths said it was clear that the widow and her family had been deeply affected.
Dr Richard Evans, clinical board director for medicine at Cardiff and Vale health board, said: "We would like to offer again our sincere condolences to the family of the deceased and our unreserved apologies for not having met the high standard of care we aim to provide to all patients.
"The health board has worked with the ombudsman and has accepted the recommendations, a number of which have already been acted upon.
"Work is under way on those that remain and we are also publishing our action plan online to clearly set out what we are doing to improve care in relation to his recommendations."