Decision Report 201402201

Summary

Mr C was diagnosed with a cataract in his eye and an epiretinal membrane (a thin sheet of tissue over the centre of the eye that can restrict vision). He was referred to The Princess Alexandra Eye Pavilion for surgery to remove the cataract with a separate procedure to follow to remove the epiretinal membrane. On the day of the surgery, Mr C's consultant ophthalmologist was absent due to illness. Mr C was offered the chance to delay the surgery until he returned or to proceed with another surgeon. He opted to proceed.

Mr C experienced complications of surgery that resulted in his retina becoming detached. He found out after the surgery that the surgeon was still a trainee and felt this should have been made clear to him before he consented to the procedure. He also complained that it took several consultations over a number of weeks to diagnose his detached retina.

We obtained independent medical advice on this complaint. We concluded that, whilst Mr C's retinal detachment was not present during the first few post-operative examinations, at one appointment it was noted that the ophthalmologist could not get a clear view of his retina. We accepted the advice that, had an ultrasound been carried out at this point, the detachment may have been identified. This could have led to diagnosis a week sooner than Mr C experienced. We also found that, whilst Mr C's consent for surgery had been properly obtained, it would have been good practice for the board to tell him that a trainee surgeon was going to carry out the procedure.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to arrange an ultrasound;
• share this decision with the staff involved in Mr C's care;
• apologise to Mr C for failing to tell him that the surgeon was a trainee; and
• share the adviser's comments on good practice with the ophthalmologists.