Decision report 201103641

Summary

Mr C complained to us about the eye treatment that he received in hospital. Mr C is registered partially sighted and felt that his glaucoma (abnormally high fluid pressure in the eye) became considerably worse while under the care of the hospital. He was concerned that they treated him without obtaining a copy of his previous medical records from a hospital in England. As he remained unhappy with the treatment, his GP referred him to another hospital. Mr C also complained that information in his medical records had been crossed out and that the board’s response to his complaint contained errors and omissions.

After taking independent advice from one of our medical advisers, we considered that Mr C had been reviewed at reasonable intervals and noted that his eyesight had not deteriorated during the time he was seen at the hospital. However, we upheld his complaint about treatment as we found that the hospital did not act quickly enough in obtaining a copy of his medical records from the hospital in England. Had this information been sought at his first clinic appointment, the clinicians would have known a reasonable target pressure for which to aim in Mr C's case. In addition, the hospital did not take an image of his optic nerves or measure the central corneal (transparent part of the external coat of the eye covering the iris and the pupil) thickness in order to ensure his eye pressure levels were accurate as possible in line with National Institute of Clinical Excellence (NICE) guidelines. We also considered that it would have been reasonable for Mr C to have been offered treatment at his third appointment. We did not identify any concerns with the information that had been crossed out in Mr C's medical records but upheld the complaint about complaints handling as we noted that the board had apologised for providing incorrect information about an appointment in their complaint response.

Recommendations

We recommended that the board:

• remind relevant staff involved in Mr C's care that a summary of a patient’s previous eye treatment for glaucoma should be requested from the previous healthcare providers at the time of their initial clinic appointment; and
• ensure that as part of the initial assessment, optic nerve head imaging and central corneal thickness measurements are carried out in line with NICE guidelines.