Decision Report 201508405

Summary

Mrs C underwent cataract surgery to her right eye at the Golden Jubilee National Hospital and had no concerns. However, she then complained about the care and treatment she received following subsequent cataract surgery to her left eye because she was experiencing pain and double vision. Mrs C was concerned that she was not informed prior to the operation that a different doctor would be performing the second surgery, that her left eye was not properly anaesthetised, and about the lack of treatment after she raised her concerns, post-surgery.

We took independent medical advice and found that it was reasonable for a different doctor to have performed the second surgery. However, we found that it should have been properly explained to Mrs C when she consented to the surgery that it could be a different doctor. In addition, we found that the consent form did not clearly state all of the known risks and complications of her surgery, which would have been accepted good practice. There was documentation indicating that some form of conversation took place with Mrs C about the risks of post-operative inflammation and the possibility that further surgery might be needed. However, we were critical that it was not clearly completed and recommended the board take further action to address these two issues relating to the consent process.

However, we did not uphold Mrs C's complaint on the basis that there was no definitive evidence to support that there was a problem with the anaesthetic or the operation itself. There was a small amount of plaque left behind but we considered it was reasonable not to remove it due to there being an increased risk of complications if removed.

We considered that it was reasonable for Mrs C to be discharged to the care of her optician after the operation. We noted that the optician referred Mrs C to a different hospital when she experienced pain and inflammation in her left eye, and that the care plan was to carry out further surgery. We considered it was appropriate for the board to advise Mrs C to continue with this suggested care plan. Whilst we did not uphold Mrs C's complaint, we were critical that there was no evidence to clearly show that the operative findings had been explained to Mrs C or her optician and that as a result of these findings she may develop inflammation and require further surgery. We therefore made recommendations to address these communication problems.

Recommendations

We recommended that the board:

• share the findings of this investigation in relation to the consent process with staff concerned;
• consider amending their consent form to include a separate section for listing all the relevant risks and complications discussed with the patient;
• draw to the attention of the doctor who carried out the second surgery the importance of sharing the operative findings and potential for further surgery with both Mrs C and the optician who managed her post-operative care; and
• apologise to Mrs C for the failings identified in this investigation.