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Koby Brown lost the sight in his right eye due to SDHB delays and missed opportunities to remedy the situation, the report says.
The SDHB may now face legal action.
Commissioner Andrew Hill is referring the case to the director of proceedings to decide whether further action should be taken.
In addition, Mr Hill ordered the SDHB to apologise to Mr Brown, provide a detailed update report within three months on steps taken to fix problems with ophthalmology services, and recommended the Ministry of Health check systems nationwide did not have the same faults.
Mr Brown believed he was not able to take the matter further as he had received a payment from ACC.
``Apparently the way it works if you receive a payout you don't have a leg to stand on ... I'm quite happy to turn the page and move on, but if someone wants to go to court on my behalf I won't say no.''
The SDHB's apology was the second Mr Brown has received from the organisation, but it was cold comfort.
``I take those with a grain of salt. I'm sort of over the apologies,'' he said.
``It's all very well saying sorry but if there's nothing going to happen about it, what's the point?''
Mr Brown, who had been a driver until losing sight in his right eye, is now a dairy farmer.
He was diagnosed with glaucoma in 2014, after an urgent referral. However, delays in follow-up appointments being scheduled meant his sight gradually deteriorated, to the point where he lost the sight in his right eye.
SDHB relied on administration staff who lacked training and clear guidance to prioritise cases appropriately, the report said.
``It was wholly inappropriate for SDHB booking staff to be tasked with the important responsibility for prioritising ophthalmology follow-up appointments without supporting those staff with sufficient training, clinical oversight and input, sufficient information on which to base prioritisation decisions, and clear direction about what might constitute a higher risk patient requiring clinical escalation.''
The SDHB's system meant the time period for treatment requested by the patient's doctor was the only criteria for assessing how urgent a case was.
With Mr Brown's case - like many others - being classed as urgent, the system quickly became gridlocked and Mr Brown's case was lost until it was too late to preserve his full vision, the report said.
The report sheeted the blame for this home to SDHB management, and said there had been insufficient response to growing demands on ophthalmology services, for many years.
``There was a lack of recognition among management at SDHB of the clinical risk caused by this lack of capacity ... delays became normalised and, as a result, SDHB tolerated a situation that put patients at risk.''
However, the commissioner praised SDHB's response since problems were revealed, saying a subsequent external review of ophthalmology services was thorough, and effective new therapies had been introduced.
That review examined 34 cases, and suggested they might be the tip of an iceberg of mishandled glaucoma cases.
SDHB chief medical officer Nigel Millar said the DHB sincerely regretted it had not met the clinical needs of patients with eye problems and Southern DHB has ``sincerely and unreservedly'' apologised to Koby Brown.
Dr Millar said the SDHB had taken the matter extremely seriously, and was working hard to bring continuing improvements to the service, eliminate the overdue appointments and ensure the service remains sustainable.
``We currently have 768 patients whose follow up appointments are classed as clinically significantly overdue (i.e. they have been waiting longer than 1.5 times the clinically recommended timeframe in relation to their conditions).
``We are holding weekend clinics in Dunedin over the next months with the goal of bringing this number to zero.''