Decision Report 201403297

Summary

Miss C complained that tear duct surgery carried out on her young daughter caused a deterioration in her daughter's vision. She raised concerns that no vision problems were detected at the preoperative assessment, however, problems were subsequently identified post-surgery and her daughter now needed glasses. The board maintained that the vision problems were not caused by the surgical procedure.

We took independent advice from one of our medical advisers. He noted that the test carried out at the preoperative assessment was a standard test for very young children. He explained that it was common for children who could only initially manage this level of testing to be able to undergo more advanced testing when they returned a little older and more able to cooperate. This was the case with Miss C's daughter and the more rigorous testing carried out at the postoperative assessment identified a modest need for glasses. The adviser said the vision problems were likely to have been caused by the underlying problem of the blocked tear duct. He did not consider there to be any evidence to suggest that they were attributable to the surgery itself.

We accepted the advice we received and we did not uphold the complaint. However, our adviser raised some concerns about the number of doctors involved in Miss C's daughter's care. He considered that there should have been one doctor overseeing the care and he felt this lack of continuity might have contributed to confusion surrounding the complaint. He also noted that, while Miss C's daughter's vision was checked postoperatively, this does not appear to have happened automatically. He advised that it would be good practice to routinely carry out vision checks following this type of surgery. We, therefore, made some recommendations.

Recommendations

We recommended that the board:

• consider mechanisms for introducing a level of continuity of consultant care into the care pathway for tear duct surgery; and
• consider the need for vision to be routinely assessed postoperatively in children following tear duct surgery.