Hywel Dda University Health Board has apologised to a woman and her family and given them £1,000 after a “failure to recognise the importance of obtaining regular and accurate levels of her mother’s immunosuppressant medication.”

A woman - identiifed in a Public Services Ombudsman for Wales report as Mrs O - complained that Hywel Dda failed to order and take timely blood tests for her mother – identified as Mrs W - while she was in the community in November 2021.

The Ombudsman found that there was a “failure to recognise the importance of obtaining regular and accurate levels of Mrs W’s immunosuppressant medication.”

“Although monitoring subsequently improved, the initial failing meant that, for the first three weeks of her admission, Mrs W’s tacrolimus levels were probably higher than usual for her and exceeded her recommended safe dose.

“This may have slightly decreased her chance of survival, although it was not possible to say that her outcome could have been different.

“This uncertainty for the family about what difference that might have made to her final days was an injustice to them.”

Hywel Dda University Health Board agreed to apologise to Mrs O and her family, and to offer her financial redress of £1,000.