Carmarthenshire News Online has agreed to anonymise all identifying details in this account at the request of the family, in order to protect their privacy while allowing the concerns they have raised to be heard. The GP surgery involved and Hywel Dda University Health Board can be named as the relevant bodies. All other names, dates, and identifying details have been changed or withheld.
Margaret, as we will call her, was a woman who had given decades of her working life to the NHS. She knew the system intimately, from the inside. When she began telling the doctors and nurses caring for her that something was seriously wrong, she did so not as an anxious patient grasping at explanations, but as a healthcare professional who recognised the signs.
They did not listen. That, at least, is the account of her daughter, Sarah, who has spent the time since her mother’s death working through folders of medical records, correspondence, and complaint documents in search of answers that she says no one in authority has been willing to provide.
A Heart Procedure, and a Decline That Followed
Some years ago, Margaret underwent a routine heart valve replacement, a procedure that went well and from which she recovered. She lived normally for well over a decade after the operation. Then, gradually, her health began to change.
What was initially believed to be a chest infection did not resolve. Over a period of months, Margaret’s symptoms worsened in ways that pointed increasingly toward cardiac distress: chest pain, difficulty breathing, and swelling in her legs. She raised her concerns with her GP surgery. She was, by her own account and that of her daughter, explicit about what she was experiencing and about her belief that something was seriously wrong with her heart.
A review of Margaret’s medical records, carried out by Sarah after her mother’s death, indicated that Margaret should have been referred to a specialist heart clinic at an earlier stage in her deterioration. Sarah is in possession of a document which she says clearly supports this. That referral, she maintains, was never made by the GP surgery.
“She had worked in the NHS for decades. She knew what she was describing. She kept telling them something was wrong and they completely ignoring her concerns.“
A Referral Made by the Patient Herself
As her condition continued to decline, Margaret became largely immobile. She was struggling with persistent breathing difficulties and other symptoms that her daughter describes as consistent with serious cardiac failure. In desperation, she reached out to a former NHS colleague, who helped her secure an urgent appointment at the specialist clinic to which her GP surgery should, in Sarah’s view, along with the actual blood test results from the GP surgery, have referred her months earlier.
When Margaret was assessed at the clinic, the reception she received was markedly different from what she had experienced at primary care level. Medical staff acknowledged shortcomings in her care. They apologised. They admitted her to coronary care immediately.
The clinical picture at that point was serious. Margaret was told she was in a critical condition and that she required a Transcatheter Aortic Valve Implantation, known as a TAVI procedure, in order to survive. She was initially treated for fluid buildup before being transferred to another hospital, where the TAVI was carried out.
Sarah notes that even during this period of hospitalisation, her mother’s wider symptoms were not fully addressed. She alleges that concerns she and her mother raised during the inpatient stay were again not taken with the seriousness they warranted. According to Sarah, Hospital notes were incomplete e.g. they left out pain scores from certain days, particularly on days where the pain Sarah’s mother experienced was particularly severe, which they have admitted to in the report.
Recovery, Then Sudden Deterioration
Following the TAVI procedure, Margaret appeared to be recovering. For a period of several weeks, there were grounds for cautious optimism. Then, without warning, her condition collapsed.
She was admitted to Accident and Emergency, where she was diagnosed with pancreatitis. The condition progressed rapidly to a severe necrotising form. Eight days later, Margaret died.
Sarah filed formal complaints with the relevant health authorities in the aftermath of her mother’s death. Her concerns covered the accuracy of Margaret’s medical records, the failure to make the earlier referral, the management of her symptoms during her hospital admission, and the overall standard of communication between the healthcare professionals involved in her care.
A Consultant’s Letter and a Timeline That Does Not Add Up
Among the specific concerns Sarah raises is a dispute about who arranged the crucial specialist referral. A cardiac consultant involved in Margaret’s care reportedly stated that he had referred her to the specialist clinic. Sarah flatly disputes this, maintaining that her mother had been compelled to arrange the appointment herself through a former colleague. This is proven by Sarah, who has since found the text communications between her mum and her colleague.
After Margaret’s death, Sarah contacted the consultant directly, asking for his assessment of the possible causes. The following morning she received a call to confirm her address, with a letter to follow. When the letter arrived, the consultant stated that he had read through all of the details of the case and could find no evidence linking the TAVI procedure to her death.
Sarah finds this timeline deeply troubling. She holds several folders of documentation relating to her mother’s case. She does not believe it would have been possible to read through the full body of material in the time available before the letter was written. She views the response as cursory and as indicative of a broader pattern of deflection.
“It would have been impossible to have read through it all overnight. That letter told me everything I needed to know about how seriously they were taking this.”
The Ombudsman: Missed Deadlines and a Remark the Family Found Cruel
Having pursued her concerns through the health board and found little satisfaction, Sarah escalated her case to the Public Services Ombudsman for Wales. The experience, she says, compounded her distress rather than alleviating it.
Deadlines communicated to Sarah by the Ombudsman’s office were missed on more than one occasion. On each occasion she had to chase for updates herself rather than receiving them proactively. When the draft report was eventually provided, it contained factual inaccuracies about her mother.
The report also included a comment to the effect that Margaret had been fortunate to have been seen at all, suggesting that at other hospitals she might not have received even that level of attention. Sarah describes this remark as callous and cruel, made about a woman who had spent her professional life serving the NHS and whose family were in the midst of grieving her death.
When Sarah requested a review of the way her case had been handled by the Ombudsman’s office, she received an apology for the missed deadlines. Nothing further was upheld. No substantive change to the findings was made.
“They told me she was lucky to have been seen at all. That is what they said about my mother.”
‘We Are Just a Number to Them’
Sarah is aware that complaints against Hywel Dda University Health Board and other NHS bodies in Wales have risen significantly in recent years. She does not find that context reassuring. She finds it devastating.
“I know the number of complaints has risen. But that just means there are more families like mine. The health board does not seem to care. They just want to avoid responsibility for the loss of real people. We are just a number to them.”
What Sarah wants is not exceptional. She wants accurate records. She wants an acknowledgement of what went wrong. She wants the questions she has been asking since her mother’s death to receive genuine answers, not letters that appear to have been written without full consideration of the evidence she has placed before those responsible.
She is also concerned about the wider pattern she believes she has observed. She does not think her case is unique. She thinks there are other families in Carmarthenshire and across the Hywel Dda health board area who are experiencing the same combination of institutional deflection and procedural inadequacy, and who do not know that others are going through the same thing.
This Is Far From an Isolated Experience
Sarah’s account is, by her own assessment, unlikely to be unique. The publicly available patient record for the two main GP surgeries serving central Carmarthen, Furnace House Surgery on St Andrew’s Road and St Peter’s Surgery on St Peter’s Street, suggests that the concerns she raises about being dismissed, not listened to, and failed by a system designed to protect her are shared by a significant number of residents in this town.
Furnace House Surgery holds a Google rating of 3.6 out of 5 from 44 patient reviews. St Peter’s Surgery, which sits immediately adjacent and serves an overlapping patient population, holds a Google rating of 2.4 out of 5 from 30 reviews, one of the lowest of any GP practice in the area. The themes running through the negative reviews of both practices are consistent and recurring.
One Carmarthen resident described his experience of Furnace House Surgery:
“Terrible service, bordering on negligent.”
Another patient described a pattern of fragmented care over the course of several weeks that left him no better off than when he started.
“The first doctor sent me for X-rays on my back and hip. Two weeks later the second doctor gave me more pain killers and told me the first doctor would be back on Tuesday. I booked another appointment and this time saw a third doctor who did not look at my X-rays. He told me it was sciatica, did not even do anything for my hip, and gave me more pain killers. This has been over a month since I saw the first doctor and I am still none the wiser and still in pain.”
A third patient raised concerns, not about the doctors, but about the conduct of reception staff.
“Receptionist very rude at Furnace House. The pharmacy is doing their very best, no need to be rude to patients. This receptionist needs a lesson in patient care.”
A fourth described an experience that will resonate with anyone who has tried to navigate GP telephone access in Carmarthen.
“For it to regularly take over two hours to get through to anyone, then just to be told we do not take bookings, call again at 8.30 tomorrow, for it to repeat, is a joke.”
This is not, as Sarah herself understands, a story about one family’s loss, though it is certainly that. It is a story about a pattern of experience that Carmarthen patients are describing across both of the town’s central GP surgeries, a pattern in which concerns are dismissed, warnings go unheeded, and patients who push back are made to feel that their persistence is the problem. Margaret pushed back for months. She told her doctors, repeatedly and with the authority of someone who had spent a career in clinical settings, that something was seriously wrong. The record of what happened next speaks for itself.
The Questions This Case Raises
Margaret’s case raises a number of questions that go beyond the individual circumstances of one family’s loss. They concern how patients with complex medical histories and significant pre-existing conditions are monitored in primary care. They concern how warnings from patients, including patients with clinical knowledge and experience, are assessed and acted upon. They concern how referrals are documented, disputed, and investigated when things go wrong.
They also concern the institutions to which families turn when they believe the system has failed them. The Public Services Ombudsman for Wales exists precisely for cases like Margaret’s. If the experience Sarah describes is accurate, the conduct of that process, with missed deadlines, factual errors in draft reports, and dismissive language, represents a failure of the safety net that is supposed to exist beneath the safety net.
Carmarthenshire News Online approached Hywel Dda University Health Board for comment. Their response, though limited, was as follows:
“Hywel Dda University Health Board takes the care and wellbeing of all its patients extremely seriously, and we are sorry to hear that former patients or the relatives of patients who received care under our health board continue to carry unresolved concerns or grief.
“We would encourage anyone who feels that questions surrounding the care of a loved one remain unanswered to contact us directly. We are committed to engaging openly and compassionately with families who are seeking information, answers, or closure, and we will do our best to support them through that process.
“If you wish to contact us regarding a concern about care provided by Hywel Dda University Health Board, please contact our Patient Relations team, who are available to assist.”
It is a great misfortune that anyone should have to experience a level of care unfitting of the services that claim to deliver the best. Unfortunately, Sarah’s search for answers in relation to her mother’s treatment on the service and subsequent death will continue. Hopefully, her story will shed some light on the practices involved and some action may be taken as a result.
The names used in this article are pseudonyms. All identifying details including dates, locations within the health board area, and the identities of individuals involved in Margaret’s care have been withheld or changed to protect the family’s privacy. Carmarthenshire News Online holds the source documentation for this account on file.
If you have had a similar experience with Hywel Dda University Health Board or with the Public Services Ombudsman for Wales and wish to share your account, please contact us at carmarthenshirenewsonline.com. Your identity will be protected.
Carmarthenshire News Online, Independent News for Sir Gaerfyrddin | carmarthenshirenewsonline.com
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