Decision report 201203622

Summary

Mr C complained that hospital staff failed to act on symptoms he developed after surgery and this led to a delayed diagnosis of ocular candidiasis (a fungal infection in the eyes). Mr C had been admitted to the urology ward (where patients with conditions relating to urinary function are treated) with a kidney infection. He also had kidney stones and it was decided that he should have a stent (a mesh tube) inserted, as a stone was causing an obstruction.

Mr C was treated for sepsis (blood infection), but it was then recorded that there was yeast in his blood cultures. He was examined by a microbiologist, who recommended that he was reviewed by an ophthalmologist (eye specialist), because fungal blood infections can sometimes spread to the back of the eye. This is very difficult to treat and can result in the loss of vision or of the eye. A referral was faxed to the ophthalmologist the following day. Mr C remained in the urology ward, receiving injections of anti-fungal medication for his blood infection.

Several days later, it was recorded in Mr C's notes that the vision in his left eye was blurred, which was discussed with ophthalmology the following day. It was noted that they would review Mr C the following week. However, the next day, it was recorded that Mr C's vision had worsened and an urgent ophthalmology review was needed. Mr C's family also raised concerns at that time. He was reviewed by an ophthalmologist that night, and ocular candidiasis was diagnosed. He was transferred to the care of an ophthalmologist two days later, but has lost most of the vision in his right eye and has reduced vision in his left eye.

After taking independent advice from a medical adviser, we found that the blood infection was identified appropriately, appropriate treatment was quickly started and a prompt referral was made for an ophthalmologist to review Mr C. However, our investigation found that the junior doctors in the urology ward failed to continue to monitor Mr C's eyes while they were waiting for the ophthalmology review, and we upheld his complaint. We considered that the microbiologist should have provided more information about the need for this. Because of this, there was a failure to assess Mr C by asking about his eye symptoms or examining his eyes. When Mr C started to display symptoms in his eyes, this should have prompted another opthalmology referral at an earlier stage, although we noted that this would not necessarily have improved the outcome for him.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to monitor his eyes; and
• make the relevant staff in the hospital aware of our findings.