Decision Report 202406700

Summary

C complained about the care provided around their eye surgery, including concerns about the consent process before surgery and the communication and discharge process afterwards. C said that they were not told that a trainee surgeon would carry out the procedure and that they were not given clear information after surgery, particularly when a complication resulted in temporary loss of vision.

In response, the board explained that supervised trainees commonly perform surgery, and apologised for not making this clearer. They also acknowledged shortcomings in communication after surgery and said that they had taken steps to improve how staff check patients’ understanding before discharge.

We took independent advice from a consultant ophthalmologist. We found that it was acceptable for a supervised trainee to perform the surgery and that it is not standard practice to name the operating surgeon on the consent form. Although it would have been good practice to explain this more clearly, the overall consent process was considered reasonable. We did not uphold this part of the complaint.

However, we found that the discharge process and communication after surgery were unreasonable. A was not told about the complication, the reason for the loss of vision, or key details about their condition before leaving hospital, and a doctor did not speak to them at that stage. We upheld this part of the complaint.

Recommendations

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

• Where a complication occurs which has an immediate impact on the patient (e.g. loss of vision), medical staff should see the patient prior to discharge to offer an explanation.

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.