Decision Report 201809025

Summary

C underwent an operation to their eye at Ninewells Hospital. C considered that they were not provided with information about the medical reasons why an operation to their eye was necessary. There were complications following this surgery. C raised concerns about what happened and why there was a failure to involve them in discussions about subsequent treatment options. C was concerned that the operation was not necessary and put them in a worse position than they had been before the operation.

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 considered that the operation was necessary. However we found that:

there was no evidence in the clinical notes that C was informed about the reasons for their options for treatment when they attended the hospital;

there was no evidence in the clinical notes that the risks of surgery were specifically discussed with C. There were the usual risks of bleeding and infection, but in this case there were also extra risks;

when C presented with severe pain after the initial eye surgery they should have been able to attend Ninewells Hospital within the same day to obtain advice from the surgical team who carried out the operation. We found that there was an unreasonable delay in C obtaining definitive treatment from the hospital after they suffered a complication from the original surgery; and

there was an unreasonable failure to include C in any subsequent discussions about treatment options after the first operation.

We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for an unreasonable failure to provide them with information about the medical reasons why an operation to their eye was necessary; an unreasonable failure to provide them with information about possible complications following surgery and alternatives to the planned operation; an unreasonable delay in them obtaining prompt advice from the surgical team at Ninewells Hospital when they developed severe pain following the eye surgery; and an unreasonable failure to include them in any subsequent discussions about treatment options after the first operation. 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:

• Information about reasons for treatment, possible complications, and alternative management of non-intervention should be provided to and discussed with the patient prior to consent for treatment being obtained.
• Patients undergoing eye surgery at Ninewells Hospital should have access to a reliable pathway where they can obtain advice urgently in the event of postoperative problems.

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.