Decision Report 201902022

Summary

C complained about a globe perforation (small hole in the eyeball) which occurred during retrobulbar injection (an anaesthetic injection given into the eye) for a left trabeculectomy (a surgical operation to lower pressure inside the eye). C reported the injection being extremely painful and felt that this should have alerted the doctor to the perforation.

We took independent advice from an ophthalmologist (a specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye). We found that there is a debate as to whether retrobulbar injections have been outmoded by alternative methods of local anaesthetic. Though we did not consider it a failing that the board used this method of anaesthetic, we suggested that they may wish to reflect upon whether the methods of local anaesthesia should be reviewed in light of the outcome of this case.

We also found that the globe perforation that C experienced should have been suspected at an earlier point. We found that whilst the pain C experienced did not indicate a definite perforation, this should have raised suspicion of perforation. We also considered that had the perforation not been suspected/identified at the time of the injection, it should have been the following day when C experienced a leakage of blood in the eye. We upheld C's complaint on this basis.

The board had already discussed the case with doctors involved in C's care, presented the case at a teaching session, and discussed the case at a clinical governance meeting. However, we made further recommendations on the basis that the board had not identified that the perforation could have been suspected at an earlier point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not suspect/identify the globe perforation at an earlier point. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Where a patient experiences marked pain at the time of retrobulbar injection; or vitreous haemorrhage following retrobulbar injection, clinicians should be alert to the possibility of a globe perforation.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.