Decision Report 201508868

Summary

Ms C complained about the care and treatment she received during and after an operation to correct a squint at the Princess Alexandra Eye Pavilion. She raised concerns that she was not fully informed of what to expect, and that doctors performed additional procedures on her eyes that she had not consented to and which were not necessary. She also raised concerns about the use of experimental medications. Ms C attended the hospital for a follow-up consultation a month later, and was concerned about the attitude and thoroughness of the consultant during this consultation.

We sought independent advice from an ophthalmology adviser and an anaesthetic adviser. The ophthalmology adviser was satisfied that the surgery was of a reasonable standard, and there were no concerns raised about the surgical treatment Ms C received. However, they noted that significant elements of the consent process took place on the morning of surgery, and that this did not give Ms C the time she needed to assimilate the information. This was compounded by the stress she felt at being called in for the operation earlier than anticipated.

The anaesthetic adviser was satisfied that the care and treatment provided were appropriate, but noted that Ms C's recall of events may have been affected by the anaesthetic, and this, combined with confusion and potential delirium, could account for her concerns about what happened during and after surgery.

We were satisfied that the care and treatment Ms C received were reasonable, and we did not uphold this aspect of Ms C's complaint. However, we found that she was not given sufficient time to consider the information provided during the consent process. We were also critical of the poor level of record-keeping in relation to consent, which meant that the board could not verify what had been discussed and when. We upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• share the findings of this investigation with the appropriate ophthalmic surgical staff to ensure that patients give properly informed consent, and that discussions are appropriately documented;
• consider developing a leaflet informing patients of what is involved in squint surgery, including the risks or side effects and the likelihood of these; and
• apologise to Ms C for the failures identified and for the distress this caused her, and provide assurances that she still has full access to NHS ophthalmology services.