Clinical assessment and diagnosis
15. On 9 August 2019, Mrs E says she attended ED at hospital A. She says she had severe head and eye pain and felt sick. She says hospital A incorrectly diagnosed her with red eye and sent her home.
16. Hospital A accepts its assessment of Mrs E’s eye was incomplete, as her visual acuity (clarity of vision) was not checked. It says it has highlighted this to the doctor to encourage learning. However, it says the management of her symptoms was in line with agreed clinical practice. Hospital A says Mrs E required an urgent assessment by an ophthalmologist due to the recent surgery to her left eye. Hospital A says this was offered to her, but she preferred this assessment to be done by the team at hospital B, who carried out the assessment and she said she would contact them.
17. On 9 August 2019, Mrs E attended ED at hospital A with severe pain in her right eye. The records show the ED doctor recorded Mrs E had pain in her right eye and had an invasive operation (vitrectomy) on the left eye the day before. The ED doctor documented a brief examination of her right eye which said ‘red, congested, watery discharge’. The ED doctor did not mention the pattern of redness seen in Mrs E’s eye. They did not carry out an assessment of the pupils, or fluorescein examination (instilling a drop of orange dye into the eye).
18. The records do not show the ED doctor checked Mrs E’s visual acuity, her ability to see objects clearly. The records fail to mention the pattern of redness seen in Mrs E’s eye, or an assessment of her pupil, or the instilling of a drop of orange dye into the eye for examination. Our ED adviser says these are essential components for assessing someone with red eye, in line with the NICE guidelines, which says it should have carried out an assessment of Mrs E’s pupils and checked her ability to see objects clearly.
19. NICE CKS says conjunctivitis is a condition with clinical features of ‘discomfort which may be described as grittiness, foreign body or burning sensation’. The records show Mrs E had severe pain in her eye and had an operation on the other eye the day before. Our adviser says given the ED doctor’s inadequate examination, the diagnosis of conjunctivitis cannot be justified. Our ED adviser says no consideration appears to have been given to serious conditions such as acute glaucoma, which may occur after the administration of medication, used in an eye operation to dilate the pupils.
20. Given Mrs E was presenting with symptoms of severe pain in her eye, red eye, and blurry vision, the ED doctors should have suspected she may have acute glaucoma in line with NICE glaucoma CKS, which says acute glaucoma should be considered in patients presenting with severe eye pain, red eye, and blurry vision.
21. We have weighed up all the evidence. We can see hospital A did not assess Mrs E in line with the NICE guidelines, which says it should have carried out an assessment of Mrs E’s pupils and checked her ability to see objects clearly. Hospital A did not consider Mrs E may have glaucoma, in line with NICE glaucoma CKS.
22. We have found a failing and have considered the impact below.
Pain management
23. Mrs E says hospital A did not manage her pain when she attended ED there.
24. The records show Mrs E attended ED in the morning. She was reviewed by a triage nurse, then an hour later she had a cannula inserted and blood tests taken. She was seen by an ED doctor. The triage nurse recorded that Mrs E had a pain score of ten out of ten. It is not clear from the records when hospital A first assessed Mrs E when she attended ED. After an hour she was given an oral dose of morphine. This was two hours and 40 minutes after she arrived at ED. The records do not show whether hospital A re-evaluated the effectiveness of the analgesia it gave her.
25. We have weighed up all the evidence. We can see hospital A did not administer Mrs E with appropriate and timely pain relief. Hospital A also did not re-evaluate the effectiveness of the analgesia it gave Mrs E, after it administered the first dose to her. This is not in line with the RCEM’s pain management guidance which says patients in severe pain should have the effectiveness of the pain relief re-evaluated within 30 minutes of receiving their first dose.
26. We have found a failing and have considered its impact below.
Referral and appointment
27. Mrs E says she was not offered a referral to the eye hospital. She says she did not refuse a referral to the eye hospital and says she had an appointment the next day at hospital B. She says her medical records have been altered to include all this incorrect information and hospital A have repeated this incorrect information in its response letter.
28. Hospital A says the assessing clinician suggested a referral to its local ophthalmology service, but Mrs E said she preferred to contact hospital B where she had her operation. She said she had a follow up appointment the next day at hospital B.
29. We have considered the information provided by hospital A in its complaints file and Mrs E’s medical records. Hospital A, in its response letter, said its response was based on clinical notes, statements from medical staff, and verbal discussions with staff. We requested it provided us with copies of the statements and records of the verbal discussions. Hospital A has confirmed it cannot locate any saved statements or records of verbal discussions.
30. Based on the available information, we can see that the plan was for Mrs E to be seen in the eye clinic, if she had any other issues. There is no entry in the medical records to confirm Mrs E refused a referral to the eye hospital, and she said she had an appointment the next day at hospital B. This is not in line with S19 of GMC, Good Medical Practice guidance, which says doctors must record their work clearly, accurately and legibly.
31. We have found a failing and we will consider its impact below.
Impact of failings
32. Mrs E says she has lost faith in hospital A’s ED services. She says she was in pain and felt like she was dying, but she was told to go home. She says she was distressed, worried and anxious. She was worried about the long term damage to her eyes. When she got home, she called hospital B, and was told to go there immediately. When she arrived at hospital B, she was examined and told the pressure in her eyes was above 60 and that she had glaucoma. She says she needed a cannula, injections, eye drops, and had to have laser eye surgery. She says she was close to losing her eyesight and was really upset at the treatment she received at hospital A. She says this caused a delay in her receiving treatment at hospital B.
33. The records show when Mrs E attended hospital A she was assessed as being in a lot of pain, and she was given a dose of oromorph. Our ophthalmologist adviser says while conjunctivitis can be uncomfortable, it is unlikely that such strong painkillers would be needed.
34. Our ophthalmologist adviser says a better assessment was needed to determine the cause of Mrs E’s painful red eye, and a realisation that she required an urgent ophthalmology review on the same day. The records do not make it clear that an ophthalmology assessment was offered, the records say ‘eye clinic review if any other issues’.
35. Our ophthalmologist adviser says this shows the severity of Mrs E’s symptoms and seriousness for urgent action had not been appreciated. Our ophthalmologist adviser says a basic understanding and ability to take a history and assess a red eye is not just for ophthalmologists but should be part of the service expected in an ED department.
36. When Mrs E attended hospital B, later the same morning, she was found to have glaucoma. She had very poor vision and high pressure in both eyes. Our ophthalmologist adviser says this can be very painful, causing a severe headache or ache in the eye. Our ophthalmologist adviser says she was treated with eye drops and medication intravenously, and she had a laser procedure to treat her glaucoma.
37. On the basis of the available information, we consider that if hospital A had carried out an adequate assessment of Mrs E, it would have made a difference to her care, treatment, and management of her pain. Our ophthalmologist adviser says the delay in Mrs E receiving treatment was relatively short. She was seen at 8.30am on 9 August at the ED department at hospital A and at 11.45am at hospital B, where she had treatment. We can see from the records on 14 August, Mrs E’s vision was much better. Our ophthalmologist adviser says high pressure over time can cause damage to the optic nerves and loss of visual field and visual acuity, but as the pressure was brought down within 24 hours, it is not likely a large amount of damage was done. We therefore cannot say on the balance of probabilities the delay in Mrs E receiving treatment has resulted in long term damage to her.
38. However, we do recognise hospital A’s failing did contribute to Mrs E being in more pain than if it had provided her with appropriate pain management. It also caused her upset and distress at being sent home while she was in pain.
What hospital A has done to put things right
39. Mrs E would like an apology and an explanation.
40. We can see hospital A has apologised to Mrs E. It says the assessment of her eye was incomplete, as it did not check clarity of vision. It says it has highlighted this to the doctor to encourage learning.
41. We can see this is an improvement, which will ensure other patients have complete assessments. It is in line with our Principles for Remedy, which say organisations should seek continuous improvement and use ‘the lessons learned from complaints to ensure that maladministration or poor service is not repeated’.
42. However, we do not think this is enough. While hospital A has apologised to Mrs E and said her assessment was incomplete, it has not acknowledged her assessment, pain management, and its record keeping were not in line with standards and guidance.