Procedure on 7 November 2023
16. Mrs L underwent a phacoemulsification and intraocular lens surgery (a procedure to remove a cataract and implant a replacement lens) on her left eye on 7 November 2023.
17. The lens inverted, and the Trust explained that Mrs L would need a second procedure to correct the problem. The second procedure took place on 2 January 2024.
18. In its complaint response, the Trust said the initial procedure was reviewed as a clinical incident and the surgeon reflected on the case with their educational supervisor and several consultants at the time.
19. GMC guidance says: ‘You must be open and honest with patients if things go wrong. If a patient under your care has suffered harm or distress, you should put matters right, if possible, and explain fully and promptly what has happened and the likely short-term and long-term effects’.
20. Our adviser told us that complications happen and can be expected in cataract surgery, and the Trust was open and transparent in its communication with Mrs L regarding the complication and established a plan to correct it. This is in line with the above guidance.
21. Mrs L also says during the procedure on 7 November 2023 she heard staff discussing the equipment failure, disagreeing on whether to take the machine out of action, and discussing fragments in her eye.
22. Mrs H told us this caused her concern and distress, as she was unsure what was happening.
23. The Trust apologised for the disquieting discussion heard between the surgical team in its complaint response.
24. Our adviser told us discussion between staff is expected when something out of the ordinary happens, however, they recognised this was not pleasant and was anxiety inducing for Mrs L.
25. Our adviser noted the staff reflected on this and management had discussions with the team around how to communicate when a patient is present. We consider this was dealt with appropriately by the Trust and is in line with what they would expect to happen.
26. As we have seen the actions of the Trust are in line with GMC guidance, we will take no further action.
Communication
27. Mrs L says she experienced poor communication from the ophthalmology service on a number of occasions between 29 December 2023 and 12 June 2024.
28. Mrs L told us this significantly contributed to her anxiety following the initial procedure and negatively affected her mental health. She says these incidents affected her trust in the ophthalmology service.
29. The Trust acknowledged and apologised for Mrs L’s experiences of poor communication in its complaint response. It explained it had discussed the complaint with staff and had since implemented a new version of the eye electronic patient record.
Summary
30. Having considered all the above, we see the Trust gave Mrs L explanations and an apology in response to her complaint. It took appropriate steps to improve services and prevent the poor communication happening again. We thank the Trust for taking action to put things right. Although the Trust has apologised to Mrs L, we do not consider the Trust has done enough to put right the impact on Mrs L.
31. Our ‘Principles for Remedy’ say where poor service has led to injustice or hardship, organisations should offer a remedy that returns the affected person in the position they would otherwise have been. When this is not possible, they should compensate them accordingly, which may include making either a financial payment for direct financial loss, or in recognition of an emotional impact.
32. Where the remedy is financial, the organisation should consider the impact of its mistakes on the individual, the length of time taken to resolve the complaint, and the trouble the individual was put to in pursuing the complaint.
33. To decide on a level of financial remedy, we consider our severity of injustice scale and review similar cases. Level three of our severity of injustice scale includes cases that involve minor pain for up to about three months and a moderate impact in terms of distress, worry and inconvenience.
34. We consider Mrs L’s impact within this level on our scale, as we think she experienced unnecessary pain for a period of at least eight weeks following the first lens procedure. We also consider she experienced anxiety and distress as a result hearing discussion during the procedure and the poor communication she experienced between December 2023 and June 2024.
35. The Trust has agreed to pay Mrs L a financial remedy of £900 in line with level three of our severity of injustice scale.
36. We are very sorry for how distressing this experience was for Mrs L. We consider the Trust has offered a resolution that remedies the impact it caused Mrs L. We thank the Trust for the actions it has taken to remedy the complaint, and we will not take any further action.