Moorfields Eye Hospital NHS Foundation Trust

4. Mr R complains the Trust performed an eye operation in April 2018 using silicone oil, against his wishes.

5. He complains, post-operation, the gel was left in for too long, leading to toxicity .

6. Mr R says he lost central vision in his right eye. This means he is now classed as partially blind, as he had previously lost vision in his left eye. This has caused significant detrimental effect to his daily life.

7. Mr R wants an independent review of his complaint with an apology and a change in service to make sure this does not happen in future.

8. Mr R had a previous operation on his left eye using silicone oil at Hospital A. This is where Silicone oil is injected into the eye during vitrectomy surgery to hold the retina in place against the eye wall. This had caused complications which led to him losing vision in the eye.

9. In April 2018 Mr R was concerned about vision in his right eye deteriorating. He attended A&E at Hospital A. They advised him to return the next day after informing him the retina was still attached.

10. Due to the issues he had with Hospital A previously, he attended A&E at Hospital B. The doctor there informed Mr R the retina had detached, and he needed an operation.

11. Mr R returned the next day and was advised gas would be used during the procedure. Gas used in retina surgery does not have to be removed. It will absorb slowly on its own. During the procedure, a doctor informed Mr R they were going to use silicone oil instead. Mr R said he tried to object but the doctor said they could not hear him.

12. After the surgery Mr R was informed the doctor had to use oil as the detachment was so substantial.

13. Two weeks later, Mr R returned for a check-up. The doctor said Mr R’s sight was 20/20 but he would need glasses.

14. Mr R had another appointment on 15 May with a doctor who said the retina was ‘beautifully’ attached. An appointment was made for 31 July to remove the oil.

15. Three days later, Mr R started to lose vision in his eye. He attended A&E who confirmed his eye pressure was low (three), and prescribed Atropine (Atropine is a non-selective blocker of muscarinic receptors, present in the retina and sclera) and a referral to attend the Vitreo-retinal department the next day.

16. Attending the next day, the doctor called in a consultant as Mr R’s eye pressure was now two. They prescribed dexa-3 (Dexamethasone is a steroid medication used to treat eye pain following eye surgery).

17. Mr R attended the post operation appointment. The doctor checked Mr R’s vision and said he had maculopathy. A maculopathy is any pathological condition of the macula, an area at the centre of the retina that is associated with highly sensitive, accurate vision. Mr R was given another appointment for laser surgery to improve his vision. At this time, Mr R found new research online that suggested the oil should only have been used as a last resort, and that it must be removed in eight weeks because of toxicity developing.

18. Doctors then agreed Mr R should have laser eye surgery which was to be done on 10 October.

19. Mr R says at the 10 October appointment, discussion was had about whether Mr R’s case should have been approached differently as there was now no chance of saving vision in the eye.

23. The law says we are unable to look into cases brought to us after one year, unless there is a good reason. We have discussed this with Mr R to understand the reasons why he could not bring his complaint sooner. We have also considered the time the organisation has taken to respond to Mr R. We appreciate how long ago this matter was first raised by Mr R and we have factored all of this into our consideration.

Date of knowledge

24. The date Mr R became aware of the issues was April 2018. This was when he was told after his operation that oil had been used instead of gas during his procedure.

25. After Mr R submitted his complaint form to us in June 2019, the complaint was passed to initial investigation. We decided the complaint was premature due to the lack of final response and resolution letter from the Trust, as the resolution meeting Mr R had with the Trust happened on 15 April 2019.

26. On 13 January 2020, we informed Mr R of this decision by email letter, and left a telephone message using the details he had given us. On the same day we wrote to the Trust and asked them to provide a final response to Mr R and answer a couple of complaint points he had raised with us, that had not yet been considered or responded to by the Trust. We contacted the Trust using the details it gave us.

27. Mr R contacted us in July 2021 to enquire about the progress of his complaint. We informed him of our decision and how we had communicated with him and the Trust in January 2020. He told us he had not received the response. We advised him to contact the Trust about the new issues he had raised with us, in June 2019, for the Trust to consider and to get the final response letter. Mr R said he would not chase this up with the Trust.

Complainant’s explanation for the delay

28. When we spoke to Mr R in June 2022, he explained the prior caseworker had informed him they would get records from the Trust, and he thought this would include the complaint file and the recording of the resolution meeting he had with the Trust. We clarified with him our decision was after this conversation, and following a review of his complaint. His complaint was not yet ready for us and we had informed him of this and asked him contact the Trust in January 2020.

29. Mr R said he had not received this letter or phone call from us. We were sorry to hear that Mr R had not received our communication. We queried with Mr R why he did not make enquiries soon after he spoke with his caseworker initially, and especially between when we issued our decision in January 2020, and July 2021. Mr R could not explain why he had not contacted the Trust for a final resolution letter nor followed up with us before July 2021.

Local resolution

30. While the final response letter is still technically outstanding, the Trust have informed us they closed the complaint in July 2020 and had no communication with Mr R after April 2019. They said they had not received the email letter we sent to them on 13 January 2020 asking them to provide a copy of the final response and asking them to consider some new issues Mr R had brought to us, that we could not yet consider.

31. We have not considered the time in which the Trust responded to the initial complaint, as the complaint was ultimately deemed not ready for us to consider and was sent back to be dealt with by the Trust and Mr R. Mr R raised the complaint to us in 2019, which was in time. What is more important, is the timeframe in which Mr R came back to us after we made our decision in January 2020. In our decision letter in January 2020, we explained the one-year timeframe we have to be able to consider complaints, and that it was important for Mr R to come back to us as soon as possible.

Decision

32. We can see we initially closed the case in January 2020, asking Mr R to raise the new issues he had raised with us to the Trust to consider before we could investigate. We also asked for a copy of the final response. We did not hear from Mr R until July 2021, almost 16 months after we made our decision.

33. Had Mr R approached the Trust promptly, as we advised, and raised the new issues he had with it, we may have had grounds to set aside the time limit, assuming Mr R provided us with the final response as soon as he received it. This would be in line with our Service Model Guidance, which allows us to put the limit to one side if the Trust has taken a long time to respond. We can see we correctly advised Mr R of our time limit and the need to come back to us promptly when we wrote to him in January 2020.

34. Unfortunately, Mr R chose not to follow our advice at that time and declined to chase up the response with the Trust. In line with our Service Model Guidance, if there has been any unjustifiable delay by the complainant, we would be less likely to set aside the time limit. We appreciate how upsetting this decision is for Mr R. While we have discretion to set aside the time limit in exceptional circumstances, Mr R has been unable to tell is why it took from January 2020 to July 2021 for him to contact us about the complaint.

35. Mr R also could not provide an explanation for not contacting the Trust within this period. We are also aware the Trust also did not action the letter we sent to it, regarding the complaint. We do, however, think that Mr R could reasonably have chased us, or the Trust sooner than he did. On this basis, we have decided to decline to proceed with this complaint as it is not reasonable to put the time limit to one side.

36. We were very sorry to hear about the difficulties Mr A faced after his operation. It is clear it has been a very difficult period for him, and we understand how much this complaint means to him.

37. It is important we consider and act within the law and we regret any further upset this decision may cause. We hope this statement clearly explains the reasons why we will not be considering the complaint further .

1. We have carefully considered Mr R’s complaint about the Moorfields Eye Hospital NHS Foundation Trust (the Trust). We were sorry to hear about his experiences and thank him for taking the time to tell us about his concerns.

2. We have decided the complaint falls outside of our time limit, and it is not reasonable for us to put our time limit aside to consider it further.

3. We appreciate how much time has passed since Mr R first complained to the Trust, and to us, and recognise this decision will be disappointing. We explain below the reasons for our decision .