Decision Report 202000229

Summary

C underwent sequential cataract surgery (a surgical procedure to replace the eye lens with an artificial one when the cataract makes the vision cloudy, specifically, in this instance, monofocal lens implantation). C complained that the board had failed to communicate reasonably with them prior to the cataract surgery, including that the risks and benefits were not explained to them and that their concerns following first cataract surgery were not taken seriously.

We sought independent advice from an ophthalmologist adviser (specialist in the branch of medicine that deals with the anatomy, physiology and diseases of the eye). We found that there was no record that C was given information about the risks and benefits of the surgery. The lack of written information about the risks and benefits of the procedure was unreasonable. We noted that this was contrary to the General Medical Council's guidance to keep an accurate record of the exchange of information. We also found that there was no record of what was discussed with C following the first cataract procedure. As there is no written record, we were unable to determine what was discussed with C when they raised concerns.

In light of the above, we considered that there was a failure to communicate reasonably with C prior to the cataract surgery and we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not giving them information about the risks and benefits of monofocal lens implantation and for not recording what was discussed with them following the first cataract procedure. 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:

• Discussions with patients following cataract procedures should be clearly recorded.
• Patients should be advised of all material risks and benefits of cataract procedures and the discussion should be clearly recorded, in accordance with relevant standards and guidance.

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.