AN INVESTIGATION into the death of a Barry man has revealed that "serious, fundamental and unacceptable failures" took place during his hospital treatment.
The Public Services Ombudsman for Wales found that failings at the University Hospital of Wales Cardiff (UHW) "significantly reduced" Graham Thomas's chance for survival following a stroke - having been admitted for an infection.
Three years after the death of her husband, Jan Thomas, of Barry Road, Barry, has received an apology from Cardiff and Vale University Health Board chief executive Adam Cairns in which he says: "We failed your husband, you and your family."
Painter and decorator Graham, 61, was admitted to hospital on April 6, 2011, following an illness which was diagnosed as an infection in his bile duct.
The first major shortcoming cited in the Ombudsman's report is the failure to prescribe Mr Thomas with his regular dose of aspirin, significant in that he had previously had heart bypass surgery, and was considered at risk of having a stroke.
The Ombudsman notes that this failure was "likely to have led" to the stroke Mr Thomas suffered on April 11.
Following this stroke, Mr Thomas was not screened for swallowing difficulties, as he should have been, but rather fed as normal.
Then a CT scan - which should have taken place within one hour, but actually took place 12 hours later - failed to recognise a further stroke of the brain.
Shortly afterwards it was confirmed that Mr Thomas had also developed "hospital acquired pneumonia".
Mr Thomas was not admitted to Llandough Hospital stroke unit until April 18 (he was take there direct from UHW), which the Ombudsman states: "Did not ensure that Mr Thomas received the appropriate care."
At Llandough Mr Thomas seemed to improve, his wife and daughter noted, until he suffered another stroke on April 26. Mr Thomas died on May 4, less than a month after being taken into hospital.
After receiving an official apology from the health board, Mrs Thomas said: "I was angry. I'm still angry now. It's not going to bring him back.
"I feel the same today as when I lost him three years ago. We haven't been able to grieve for him. You have all these meetings and you feel like you're not getting anywhere."
Daughter Sarah O'Brien said: "You don't have any closure, it's taken nearly three years for that.
"You expect people to go into hospital and get better. You think you're in the best place, especially when he had a stroke in hospital, not out and about."
Mrs Thomas added: "You know that something is wrong but you just have to take their word that they know what they're doing. I just hope this doesn't happen to anyone else."
Mrs Thomas said that one small relief was that the health board has begun making changes to its procedures in light of her husband's death.
Acting Ombudsman Professor Margaret Griffiths made several recommendations to the health board to ensure better practice and noted that she has already seen changes being implemented. She also recommended that they pay Mrs Thomas £5,000.
Concluding her report, she said: "In my view, the failings identified by this report indicate the existence of both individual and systemic errors. These were serious, fundamental and unacceptable failures.
"There is no doubt that the service failures identified have resulted in an injustice to Mrs Thomas and her family."
In his apology to Mrs Thomas, health board chief Adam Cairns said: "The health board has accepted the Ombudsman's report in full and will be acting upon the recommendations.
"I appreciate this does not mitigate your experience and I am so sorry that the care your husband received was not of an acceptable standard.
"We failed your husband, you and your family and I am so sorry that we cannot change that."