Deaths like this just should not happen. We see far too many of this type of case. We are all human, and even doctors make mistakes, but for someone to die due to the length of a waiting list is unacceptable.
The ombudsman found Mr Jones had waited nearly twice the recommended time for surgery and the health board failed to warn the family of symptoms which would have alerted them to the fact he needed urgent medical treatment in the days before his death. He also found there had been previous near misses with patients waiting for this type of surgery which should have prompted the health board to ensure every possible action was taken to minimise the risk of harm to ACHD patients. There was an apparent lack of urgency for treatment for ACHD patients within the health board as a whole, the investigation found.