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Health and Disability Commissioner Anthony Hill has released a report finding the SDHB's inaction in addressing the demands on its ophthalmology service failed both the man with glaucoma and its staff.
The man had been treated for his complex glaucoma since 2006, which included regular visual-field testing.
In 2015 the man's visual-field testing was delayed until April 2016, five months later than usual, to allow time for his vision to recover after cataract surgery.
But he was not seen by a specialist until July 2016, 18 months after his last test, despite his wife contacting the SDHB several times to ask about a specific date for the appointment.
''My wife became very concerned about me not receiving any appointments plus follow-up that would be required, and after phoning the eye clinic several times to find out what was going on, she was told they had lost me in the system.''
Between the two tests the man had developed advanced glaucomatous and visual-field defects, which meant he lost vision and could no longer drive.
Eventually he required trabeculectomy surgeries in each eye.
The SDHB told the commissioner the reason for the delay in the visual-field appointment was related to demand on its ophthalmology service.
It was the inaction to address the issues with its ophthalmology service which failed the man and SDHB staff including the specialist who treated him, the report said.
The SDHB relied on administration staff who lacked training and clear guidance to prioritise cases appropriately, which was not appropriate, the report said.
Recommendations from an earlier report which found the SDHB accountable for a Mataura man going blind also applied in this case.
Mr Hill wanted to be updated on the work being done to fix the backlog and address the issues highlighted in both reports.
He also ordered the SDHB to apologise to the man.
Surgical services and radiology medical director Stephen Packer said the SDHB accepted the commissioner's opinion and sincerely regretted the man's clinical needs were not met.
The SDHB commissioned an independent review of its ophthalmology department in 2016 which led to a number of changes. It was continuing to improve its services and eliminate overdue appointments.