Hywel Dda board criticised over patient Henry Clark
A cancer patient who was supposed to receive regular check ups says he was devastated when he was finally seen and told the disease had spread.
Retired teacher Henry Clark from Narberth, Pembrokeshire, needed three-monthly check ups at West Wales General Hospital, Carmarthen.
But "serious failures" meant he was not seen for more than a year.
Hywel Dda Health Board has been criticised for what happened and has apologised.
Public services ombudsman Peter Tyndall called for a review of appointments systems and made other recommendations.
The health board said it had taken action to prevent the situation from arising again.
The ombudsman's report said Mr Clark complained about his follow up care after he was diagnosed with prostate cancer.
He was treated at West Wales General Hospital, run by the former Hywel Dda NHS Trust.
In 2008, he was told the cancer was "non aggressive" and a further biopsy would be done a year later, but he would be given a follow up appointment in three months.
However, no follow up appointment was made and, after his own inquiries, he was not seen until more than a year later.
Speaking on Monday, Mr Clark said he was okay but his future remained uncertain.
He described hearing the news that his cancer had spread as "devastating at the time".
"During that year they said they'd keep an eye on me and I thought, surely they know, and not to worry," he said.
"Then I got called in late 2009 and, when I went to the clinic, the nurse said to me, quite surprised, 'haven't you been seen since 2008?'. Alarm bells began to ring then.
"The cancer had spread from the prostate across to the body which was devastating at the time. They started treatment straight away."
The ombudsman's report said the "investigation uncovered serious failures" into the case of Mr Clark, whom it referred to as Mr C.
In summary, it said the health board's urology service "at the relevant time had an appointment backlog of over 11 months", and that "no effective or urgent action was taken to address the increasing backlog within that time".
It also said there "were no written procedures for appointment making which was a function of the medical records department".
It added there had been "a consequential breach of NICE (National Institute for Health and Clinical Excellence) clinical guidance".
The report said: "All shortcomings had severe consequences for Mr C.
"The ombudsman was very critical of these fundamental failings which he felt called into question the health board's governance and potentially placed more patients at risk."
It added: "Mr C said he felt very let down, and angry as he no longer knew what the future held for him. He could only hope that the treatment was successful.
"Mr C added that had he known then what he now knows, he would have contacted the health board to inquire about an appointment at three months, but he trusted the doctors to take care of him."
Recommendations were made, including that the health board offer an apology and "redress of £3,000 to Mr C for the failures and distress caused to him".
Hywel Dda Health Board chief executive Trevor Purt said: "Firstly, I would like to apologise to the patient for the failures identified in the ombudsman's report.
"We fully accept the findings of the report and have undertaken immediate action to ensure such a situation will not happen again."
He said all cancer outpatient lists had been reviewed along with a review of all other outpatient lists to ensure patients are being seen at the right time.
Mr Clark said: "I don't know what the future is going to be, nobody does. But I suppose mine is more in jeopardy..."
"At the moment I'm OK, and in any event I'm keeping track on all my appointments and blood tests and making sure there is no repetition."
The health board said patients with any concerns should call the board on 01437 771279 or 771225.