Hywel Dda health board 'lack of respect' over NHS complaint
A mother was treated with an "appalling lack of respect" by a health board after she complained about the care her son received, the ombudsman has said.
The woman was left waiting nearly two years for a response after she brought up issues with her son's eye treatment.
The Public Ombudsman for Wales said the delays in dealing with the complaint by Hywel Dda University Health Board were "unacceptable".
He took the "exceptional step" of issuing a special report.
It was the first of this nature issued to a health board, ombudsman Nick Bennett said.
It is a process followed if an institution or body fails to respond adequately to the ombudsman and gives them a series of recommendations.
The ombudsman became involved in the case after the woman originally complained to the health board in June 2014 and made a further complaint in January 2016 due to the lack of update on the investigation.
Mr Bennett found a number of delays in dealing with her complaint were "excessive" and the lack of updates amounted to maladministration.
"To not resolve this after nearly two years shows an appalling lack of respect towards Ms A (the woman) and her son, and has added unnecessary stress to Ms A's family," he added.
Since publishing the special report, he said the health board had agreed to implement his recommendations, including responding to the woman's initial complaint, along with apologising for the time taken to address her concerns.
The ombudsman added: "I still have serious concerns about the health board's management of its complaints handling function and its candour and governance, and will be monitoring it closely over the coming months."
Steve Moore, chief executive of the health board, said he wanted to "unreservedly apologise" for the handling of the complaint, adding "all actions required by the ombudsman have been undertaken".
"We acknowledged last year that our ability to respond in a timely way to all concerns was not fit for purpose, as we had acquired a significant backlog," he said.
"This is not an excuse but an explanation of where we were.
"Since then, we have invested the time and money to address this and made significant improvements to our ability to manage concerns appropriately and in a timely way."