The Trust did not use anaesthetic
16. The BJA helps us understand what would usually happen. It says by 2010, 59.1% of vitreoretinal surgery was done under local anaesthetic. This is for any operation to treat eye problems involving the retina, macula and vitreous (gel like) fluid. The BJA also says that clinical practice is moving away from the use of general anaesthetic for this type of surgery. Miss L needed vitreoretinal surgery to repair the damage to her retina.
17. The BJA also identifies reasons why someone would not have local anaesthetic. These are referred to as contraindications.
18. Absolute (definite) contraindications to local anaesthetic include patient refusal, allergies and localised sepsis (infection).
19. Relative contraindications include: • inability to lie still • poor compliance with instructions • communication difficulties • postural difficulties • confusion • grossly abnormal coagulation (clotting) • perforated globe or trauma.
20. Miss L’s medical records do not note any of these issues so our anaesthetist adviser explained there was no reason not to give local anaesthetic. We understand Miss L says the Trust completed her procedures without anaesthetic. Her records show she had local anaesthetic in line with the BJA guidance.
21. We appreciate these procedures were unpleasant and recognise people’s perceptions of pain vary. We are unable to comment on the pain Miss L was in at the time. Her medical notes from after her surgery on 4 October 2018 record that she did not complain of pain when in recovery.
22. The surgery notes also say there were no complications or suggestions that Miss L was concerned about pain levels during the procedure. There were no issues with her ability to keep still during the operation, which our anaesthetist adviser said would not have been the case if she had been in pain.
23. Miss L’s post-surgery notes from 4 January 2019 record that she did not complain of pain during or after the procedure.
24. From the evidence we have seen, it seems the Trust gave Miss L local anaesthetic in line with BJA guidance when it did both operations. We are sorry to learn that Miss L found both operations painful.
The Trust tore her retina and left silicone oil in her eye
25. Miss L’s medical records show a history of complex retinal detachment and note her right eye was her ‘good eye’. Miss L also had macular detachment when she was diagnosed with retinal detachment on 13 September 2018.
26. NICE guidance on the management of suspected retinal detachment explains that the success of surgery depends on the type of retinal detachment someone has at the beginning, such as whether the macular was involved. It says a retinal tear often happens before full retinal detachment. The RCO says 50% of people with untreated retinal breaks will progress to retinal detachment.
27. The RCO and RNIB explain that vitrectomy is the most common surgery for retinal detachment in the UK. It is a procedure to reattach the area of the retina that has become detached and uses a gas bubble to hold the retina in place while it heals. The gas slowly disappears after the operation. In some cases, the doctor may choose to use silicone oil instead of a gas bubble. This keeps the retina in place like the gas bubble, but surgery is needed to remove the oil at some point.
28. Our retinal surgeon adviser considered the records and, from the information available, it seems the surgery was appropriate and done in line with NICE guidance on the management of suspected retinal detachment. There is no evidence that anything went wrong during the operation and no evidence that the surgeon scratched or tore Miss L’s retina during either operation.
29. Our retinal surgeon adviser said silicone oil is used in more complex procedures (approximately 10% of procedures). They explained that it was appropriate to have left the oil in Miss L’s eye. This is supported by NICE guidance which explains a gas or oil bubble is used to span and close the retina break until a scar develops.
30. Our retinal surgeon adviser explained that the decision to then remove the oil was a clinical decision based on the impression that Miss L’s retina would remain attached. They explained it was appropriate to remove this as she had a better sight prognosis after it had been removed.
The Trust failed to communicate the possible outcomes of the surgery
31. Miss L’s medical records show that after the Trust diagnosed her retinal detachment on 14 September 2018, it offered her emergency retinal detachment repair surgery. They note that staff explained delaying the surgery to her right eye could lead to irreversible damage and blindness. There is a record that the team had a similar discussion with her on 26 September. Miss L declined the surgery because she wanted to have a different procedure first and speak to her consultant.
32. The GMC guidance helps us understand what should have happened. It says, ‘you [doctors] must give patients the information they want or need to make a decision’. This will usually include diagnosis and prognosis, the potential benefits, risks of harm and uncertainties about success of treatment. We can see the Trust shared information with Miss L on 14 September and 26 September, giving her information about her condition and its likely progression, including the associated risk factors.
33. Miss L’s medical records include signed consent forms for the procedures.
34. The consent form for October 2018 identifies the benefits of the procedure as to improve Miss L’s vision. The signed consent form also says the complications can include cataracts and further retinal detachment.
35. The consent form for January 2019 highlights the same benefits and complications as the last procedure, but also says the risks include possible loss of vision. There is nothing in the records to show Miss L had any concerns about the forms themselves and she signed to say she had understood the information she had been given.
36. It seems the Trust gave information to Miss L about the possible outcomes of her surgery, in line with the GMC guidance.
37. We understand how difficult it has been for Miss L to bring her complaint to us and do not underestimate the challenges she has faced. We thank her for bringing this to our attention and hope we have explained our decision clearly.