Decision Report 202405410

Summary

C complained to us that the board failed to provide them with reasonable care and treatment during an appointment for a cataract procedure. We took independent advice on the complaint from a consultant ophthalmologist. We found that the scratch on the lens was not caused by the doctor but rather by the folding process of the lens in the lens introducer. However, it was unreasonable that a large scratch on the lens had not been identified after it had been inserted during the procedure. Had the issue been noticed at the time of the procedure, C would have been put into an informed position regarding the issue, of the symptoms that they would likely experience and the plan to remedy the issue. It could have been resolved much sooner, thereby lessening the pain and discomfort C endured over an extended period of time and the subsequent effect this had on their life.

C also complained that the board failed to provide reasonable follow up care and treatment following the appointment. We found that early follow up and intervention by the board would have allowed for a relatively straightforward lens exchange. Better information and communication throughout this process would have allowed for smoother patient care. Therefore, we upheld both of C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaints considered. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients should receive appropriate follow up care and treatment and a review appointment should be promptly arranged at the hospital when this is appropriate.
• Surgical staff should routinely inspect the intraocular lens post insertion.