Decision Report 201305357

Summary

Mr C complained on behalf of his wife (Mrs C) about the care and treatment she received at the Princess Alexandra Eye Pavilion. Mr C said that mistakes were made during an operation, and that his wife was left virtually blind in her left eye. Mr C also complained about the board's response when his wife complained about this.

During our investigation, we took independent medical advice from an experienced cataract surgeon. The advice we received was that the care and treatment Mrs C received was appropriate and that no mistakes were made during the surgery. Mrs C had, however, suffered two rare complications. While the advice we received was that, in general, both complications were handled well, there was a small error in relation to the first one, in that the vitrector (a machine used in eye surgery) used as a result of the complication was not tested before it was used on Mrs C's eye, and was not working. Our adviser said that this was unlikely to have had a material impact on the outcome and was not the cause of the second complication, but we were concerned that the machine was not fully tested before it was used. We were satisfied that there was no evidence that work continued on Mrs C's eye after it was discovered that the machine was not working.

We did, however, find that the complications that arose in Mrs C's case were not discussed with her before the surgery and were not included in the information leaflets that she was given. In addition, we were concerned that Mrs C was not given enough time to make a considered decision about the surgery. We were also concerned about the handling of Mrs C's complaint - in particular that the response she received to her representations contained unnecessary, confusing details and did not meet her needs.

Recommendations

We recommended that the board:

• ensure that the relevant staff members are made aware of our adviser's view that it is wise, where a vitrector has been set up, that the flow of fluid through the vitrector is checked and that a check is carried out to ensure the guillotine cutter is working before it is used;
• consider the process for informed consent for cataract surgery to ensure that it complies with guidance about informed consent, in particular, in relation to the information provided about serious or frequently occurring risks;
• draw to the attention of relevant staff our adviser's comments that where potentially serious complications have occurred it would be wise to make a note in the medical records of the discussions held with patient/relatives;
• apologise to Mrs C for the handling of her representations; and
• ensure that their written responses to complaints meet the needs of the patient in relation to tone and language etc.