Ombudsman criticises GP out-of-hours failings in Carmarthen after death
A health board's out-of-hours service has been criticised after a woman died hours after a GP in Carmarthen failed to diagnose sepsis.
The Public Services Ombudsman for Wales said there had been "fundamental failings" in Hywel Dda Health Board's service at West Wales Hospital.
There was no record of Glenda Thomas, 67, getting a basic examination before she was misdiagnosed with shingles.
The health board apologised and said it fully accepted the findings.
Meanwhile, Mrs Thomas's husband Roger told BBC Wales he was pleased there could now be closure.
"I just wanted the doctor to admit he'd made a mistake," he said.
Mrs Thomas, from Llandeilo, had previously been treated for cancer and had a condition known as lymphoedema and was prone to infection.
Sepsis occurs when the body has a severe reaction to bacteria or germs.
It is said to kill 1,800 people a year in Wales.
In his report, the Public Services Ombudsman for Wales Peter Tyndall said the woman, referred to as Mrs R in his report but later named as Glenda Thomas, had been feeling unwell and had developed a rash on her left arm in May last year.
Mrs Thomas was told to visit the out-of-hours GP service at West Wales General Hospital, Carmarthen, which is run by Hywel Dda.
But Mr Tyndall's investigation found there was no record of the GP performing a number of basic assessments including temperature, pulse, and blood pressure.
The GP diagnosed a case of shingles and Mrs Thomas was given a prescription for a common antiviral drug.
But the following morning she collapsed at home and was admitted to A&E at the same hospital.
She died later that day from complete organ failure as a result of sepsis.'Fundamental errors'
The ombudsman's clinical advisers found that there was an "evident failure" by the GP to consider that Mrs Thomas could have developed an infection as a result of her lymphoedema.
The GP should have ruled out the blisters as a symptom of sepsis, said Mr Tyndall's report.
The ombudsman also criticised the health board's complaint handling.
These included delays, fundamental errors in letters and a failure to respond to a relevant third party.
Mr Thomas, who brought the complaint, told BBC Wales: "This is a damning report. If he was any kind of doctor he would have taken her temperature and her blood pressure.
"I had to ask him to look at her, her left arm was twice the size."
"I didn't want money, I didn't want anything. I just wanted the doctor to admit he'd made a mistake."
"I'm pleased there's closure for us all."
In accepting Mr Tyndall's recommendations, Hywel Dda Health Board will make a written apology to Mr Thomas.
The board has made a payment of redress of £4,000 to Mr Thomas for the failures identified in the care of his wife and £500 for the complaint handling failures.
A statement said: "The health board would like to apologise to the patient's family for the failures identified in the ombudsman's report.
"We fully accept the findings of the report and are in the process of carrying out the ombudsman's recommendations.
"We will also be sharing the report widely to ensure lessons are learnt."
A sample review of the GP's out-of-hours clinical consultation records will be taken and all GPs delivering out-of-hours services will be reminded of the importance of performing full assessments of patients and making a proper record.