12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen.
13. If we find possible indications of failings, we then consider whether there are signs the events complained about had a negative effect which the organisation has not put right.
Pain relief
14. Mr A complains a consultant at the Trust failed to ensure he had adequate pain relief during the cataract extraction and lens implant operation on his right eye he had on 30 May 2024. He says he experienced a sharp pain in his eye during the operation, and he ‘yelled and crushed the nurse’s hand’.
15. He says the nurse acknowledged his pain and raised this with the consultant. He states the consultant’s companion, who he assumed to be another doctor, said ‘that’s deep, probably due to uveitis’, but no further pain relief was given.
16. The Trust said the documentation of the procedure did not note any issues with pain were raised. It apologised Mr A’s experience was not acknowledged with appropriate empathy. It said when pain relief is injected into the eye the injection can be uncomfortable or cause short, sharp pain in some instances. This would not be classed as a complication and therefore is not normally documented in the notes. It said Mr A’s procedure went smoothly and there were no clinical complications or concerns.
17. NG77, section 1.7 states doctors should give pain relief by both topical (eye drops) and injection method for cataract surgery.
18. The records set out Mr A received proxymetacaine local anaesthetic drops, preoperatively (immediately before a surgical operation). He also received oxyuricide local anaesthetic drops and an in eye of local anaesthetic injection of lidocaine 1%. Our adviser informs is this was in line with appropriate standards for cataract surgery under topical analgesia.
19. There is nothing in the notes to indicate appropriate pain relief was not provided during the procedure.
20. We understand Mr A feels the Trust records are inaccurate. He has described experiencing pain and this being acknowledged by the medical professionals. We do not dispute his recollection of events. As we were not present, we cannot say exactly what happened during the procedure. We have not seen any further supporting evidence to suggest his pain levels were over and above what would normally be expected. Our adviser agreed that administration of local anaesthetic can in itself can be uncomfortable.
21. We have seen the methods of pain relief provided during the procedure was in line with NG77. There is nothing in the records to indicate concerns around pain relief were raised during the operation. We therefore will take no further action on this complaint. We understand this will be disappointing for Mr A.
Consent
22. Mr A complains the Trust failed to fully inform him of the risks of the procedure during the consent process. Specifically, he says he was not told there was a risk of sight loss from the surgery.
23. Mr A told us on 18 March 2025 he signed the first consent form. He said this was done with full disclosure. He said when he signed the second consent form, on the day of the operation, he was rushed and pushed to sign it as soon as possible.
24. The Trust said the risks and benefits of the procedure were fully explained to him by the consultant on 18 March, with particular attention being paid to uveitis (inflammation of the eye) and possible loss of vision.
25. NICE guideline NG77, sections 1.1 to 1.5 set out the information it is recommended to give patients prior to cataract surgery. This includes details of the risks and benefits of the procedure.
26. The Trust, Consent to Examination or Treatment Policy, section 6.43, states information should be provided, options discussed, and initial consent obtained, normally well in advance of the procedure.
27. It further states a second confirmation of consent should be obtained, to ensure the patient still wants to go ahead, and this is often done on the date of procedure.
28. The records from 18 March 2024 include a consent form signed by Mr A with an explicit line documenting the risk of ‘Detached retina: peeling off of the seeing layer of cells in the eye’. This was countersigned by the consultant ophthalmologist. It also highlighted a 1:1000 risk of complete loss of vision in the operative eye.
29. The records indicate at his pre operative assessment on 28 May, the doctor asked questions about Mr A’s health, including his diabetes (which can affect eyesight).
30. The records show when Mr A objected to such questions, the consultant is documented as advising they were needed to ensure he was suitably fit for the procedure.
31. Mr A confirms he signed the consent form on 18 March, and on the date of the procedure. The evidence provided by the Trust does not indicate he raised any concerns at the time, or any future point, including the date of his procedure about the procedure.
32. We have not seen Mr A was not unable to communicate any concerns he had with Trust staff, verbally, or by email or letter. In the records from his pre operative review on 28 May specifically he is documented as being quite vocal in his communications with staff.
33. Our adviser informs us Mr A’s history of uveitis meant that the material risk of detachment, inflammation and swelling of the eye would be higher for him than standard patients.
34. Improved information regarding the relative risks on the consent form may have helped in Mr A's instance, specifically regarding retinal detachment risk. However, the information provided to him prior to the procedure was in line with NG77 and NICE CKS Scenario: Management of cataracts in adults.
35. We consider the Trust consent process was in line with the NG77 and Trust policy, and the Trust provided Mr A with the appropriate information he needed.
36. As his initial consultation was on 18 March, he was reviewed preoperatively on 15 May and had the procedure on 30 May 2022. We consider the Trust provided Mr A the opportunity to raise any concerns he may have had before the procedure.
37. We understand how strongly Mr A feels about the consent process. We will be taking no further action on the complaint. We hope our explanation helps him understand our reasoning.
Procedure
38. Mr A complains the Trust incorrectly performed the procedure as he had uveitis (inflammation affecting the middle layer of the eye).
39. The Trust said there was no indication of uveitis present in his preoperative consultations. It also said accepted literature says it was reasonable to go ahead with the surgery if a patient had been clear for six months. At the date of his operation, 30 March 2024, Mr A had been clear of uveitis for a year. The Trust said the surgery noted it was a routine procedure, documenting it was uneventful, and no complications were encountered.
40. There is no specific guidance relating to uveitis and surgery. GMC Good medical practice, section seven, states when providing clinical care doctors must adequately assess a patient’s condition(s), taking account of their history, including any symptoms, and carry out a physical examination where necessary.
41. The records show preoperative checklist in Trust records notes there are no indications of infection on 30 May. Operation notes indicate there were no complications in the procedure.
42. Mr A also states he received an apology, on 23 October, from the consultant who reviewed him. There is not documentation of this conversation in Trust records.
43. We recognise Mr A believed his surgery should not have gone ahead when it did. We acknowledge his further statement he was aware the procedure could go ahead, but feels doing so at the venue it did, was incorrect. We have seen appropriate assessment was carried out in line with GMC Good medical practice and there was no indication of infection prior to surgery and there was nothing to indication the surgery could not go ahead when it did. We therefore will take no further action.
Venue
44. Mr A complains the consultant who saw him on 18 March 2024, when he completed his first consent form, told him he would ‘need to go to a place of excellence, so if something goes awry it can be dealt with’. He states as the procedure took place in a cottage hospital, which was not properly equipped, this did not happen.
45. The Trust said his procedure took place in an appropriate location, considering his symptoms and medical history. It also noted it was a routine procedure and no complications were encountered.
46. We acknowledge Mr A says he requested the procedure be done at a place of excellence, and his says he signed the consent form ‘on the understanding my request would be honoured’.
47. We have seen no documentation of a conversation held with Mr A which states the procedure would take place in a specific place.
48. Our adviser informs us Mr A’s conditions and past medical history would suggest the need for an experienced surgeon rather than predicating a specific location.
49. The RCO publication, The way forward, makes it clear cataract surgery can be done in a variety of settings. Our adviser informs us they can see nothing which indicates the hospital Mr A had his procedure at was not suitable. It is noted the hospital is registered with the Care Quality Commission (CQC) as able to perform surgical procedures.
50. We consider the procedure took place at an appropriate location. Based on the evidence provided by Mr A and the Trust, it is our view there are no indications he was promised his procedure would take place in a particular place. We therefore will take no further action.
Post operative advice, check and referral
51. Mr A complains he was not provided with correct post operative advice. He also states he saw his optician on 8 August 2024 who told him he had a detached retina in his right eye and urgently referred him to the cataract clinic.
52. He states he attended the clinic the same day and the consultant at the Trust failed to see the retina was detached in his right eye, and failed to refer him for treatment of his detached retina.
53. Mr A provided two witness statements to us as part of his complaint evidence. The first statement Mr A provided from Ms R, a friend and tenant of Mr A, states the consultant ‘confirmed the detached retina in the right eye’ and stated ‘which presumably occurred during the surgical removal of the cataracts’. It states the consultant discussed this, the need for an urgent consultation, and possible surgery. The writer of this statement makes it clear they did not attend the appointment with Mr A.
54. The second statement, from Miss I (relationship to Mr A unknown), states they attended the appointment with Mr A. It says the consultant used an optical scanner to examine his right eye. It further states when asked by Mr A if the damage could have been caused by his recent surgery, stated ‘it may have been’. It also states the consultant said he would ‘need to speak to his boss in the morning’ as Mr A would need to be referred.
55. NICE NG77 section 1.1.5 states on the day of surgery, after the operation, give people information about: • what visual changes to expect • signs and symptoms of potential complications to look out for • any restrictions on activities, for example, driving • possible problems and who to contact • emergency situations and who to contact • eye drops • pain management • their next appointment and who they will see.
56. Mr A underwent his surgery 30 May 2024. Trust records indicate Mr A was discharged on a standard dose of steroids and stated he was able to administer these himself. It is reasonable to assume details about the eyedrops and any concerns to watch out for were discussed with Mr A at this time, although this is not specifically documented.
57. He had a face-to-face review 3 July. This was 34 days later. Our adviser informs us, considering current pressures on NHS services, this timescale is acceptable.
58. Records indicate on 3 July the examination performed included a dilated retinal examination, in line with NICE publication, How should I assess a person with suspected retinal detachment?
59. This states an examination should be performed to check for retinal detachment. This examination should include checking the patient’s sight level, type and size of floaters in the eye and peripheral field loss. The records indicate, and our adviser agrees, this did not reveal the retinal attachment which was later diagnosed. Mr A did show swelling of the centre of the eye on this occasion.
60. The records show the decision was made to increase the steroids Mr A was taking and he was started on a non-steroidal anti-inflammatory drug to manage this (common) post operative complication. Our adviser said this was the correct action to take, especially considering his history of uveitis.
61. Mr A’s records demonstrate that there was no evidence of a retinal detachment on a dilated retinal examination on 3 July 2024. It was not therefore appropriate to refer him for further investigations or surgery at that time.
62. Mr A’s later review, on 8 August, was 88 days after his procedure was performed. This took place following a visit to his optometrist on an acute and non-elective basis. It was at this point that the retinal detachment was detected.
63. Mr A states this later review only occurred as his optician, who he saw that day, referred him. As we have set out above the initial post operative check was performed 34 days after the procedure, which is an acceptable timeframe.
64. We understand how upsetting and worrying it is to experience complications after surgery. It is understandable to cause a patient to question what may have gone wrong.
65. It is our view the Trust provided appropriate post-operative advice to Mr A. The post-operative checkup was carried outs in line with NICE NG22 and the publication, How should I assess a person with suspected retinal detachment?
66. It is not possible to say with any certainty if the detachment of the retina happened sometime during later July or early August prior to his visit to the optometrist. We have not seen any indications of failings regarding the checkup examination performed on 3 July, and there was no requirement for a referral for further investigations/surgery at that time. We therefore will take no further action on this complaint.
Complaint investigation
67. Mr A complains the Trust failed to conduct an adequate investigation of his complaint.
68. NHS Complaint Standards recommend organisations are open, specific and address all concerns raised. It also recommends organisations should make sure patients have a contact during the investigation, are updated at regular intervals, acknowledge any failings found and provide reasonable remedies in such cases.
69. Trust records document Mr A made his complaint to the Trust on 8 August 2024. He received a written acknowledgement on 13 August, following a telephone conversation with Trust staff on 12 August.
70. The acknowledgement advises him, due to the concerns he raised, the Trust allocated 50 working days to conduct the investigation. The response was issued on 24 October.
71. Mr A wrote to the Trust again following receipt of the response. This letter states it was ‘initiated 26 October 2024’, and in it he said he called the Trust on 25 October but was unsuccessful in reaching anyone and left a message. He further states he received a call back on 30 October advising he was in the process of writing his response to the Trust response, dated 24 October.
72. The Trust complaint file indicates Mr A received a call from the Trust on 25 November, during which a meeting was offered. This is in line with section 9.2 of the Trust Complaints & Patient Advice & Liaison Service (PALS) Policy.
73. Mr A is noted as not responding directly to this offer and saying he just wanted his questions answered.
74. It is our view the Trust’s complaint investigation was in line with both NHS complaint standards, and the Trust’s complaint policy. This is because the two Trust responses are detailed, addressing each of Mr A’s concerns in turn. They make it clear the clinical team who were involved in his care were consulted as part of the complaint, and his medical records were reviewed.
75. The initial response, of 24 October 2024, gave him details of how to raise any further concerns. The final response, dated 17 March 2025, provided Mr A with the details he needed to contact the Ombudsman if he wished to.
76. It is therefore our decision this component of Mr A’s complaint should be closed without further action.
Reasonable adjustment
77. Mr A complains the Trust failed to comply with the Equality Act as it did not provide information in large print. He states the text messages he received, and the consent form was in a small font, meaning he was unable to read them, and the response to his complaint was also in too small a font.
78. The Equality Act 2010, section 20 states organisations must make reasonable adjustments for disabled people, where a ‘physical feature puts a disabled person at a substantial disadvantage in relation to a relevant matter in comparison with persons who are not disabled, to take such steps as it is reasonable to have to take to avoid the disadvantage’.
79. The copy of the Trust’s response provided by Mr A, dated 24 October 2024, appears to be in size 12pt font. In it Mr A asks the Trust to note his records that all letters and leaflets be provided in size 22 font so he can read it. The response confirms an alert has been added to ‘your profiles within the patient record system’ to advise staff he required communications in a larger font.
80. The Trust advised Trust text messages are sent in a standard font, and the Trust’ digital team advise this cannot be changed. It advised Mr A it is his phone’s font setting in which the messages will appear. If he wished to view messages in a larger font, he would need to alter the settings on his phone.
81. The Trust said the consent form and information leaflet were provided in standard print and at no point did Mr A mention to staff he was not able to read these. It also states the consultant advises all risks and benefits of the procedure were clearly explained to Mr A, with particular attention being paid the risks associated with uveitis and vision loss.
82. The vision in Mr A’s left eye was noted to be of a satisfactory level to allow him to read standard print prior to the procedure. The Trust said if he had raised the issue of not being able to read the information, staff would have made alternative arrangements to make sure he had all the information he required, in a format that suited him.
83. The Trust apologised its previous response was not in large print and reassured Mr A there is an alert on his profile to say he needs this and that he should receive all communications in font size 22 going forward. It also said staff will be happy to provide blown up copies of the standard leaflets, if requested.
84. We consider the remedy provided to Mr A, of an apology, and service improvements, is in line with NHS Complaint Standards, which states organisations should be open and accountable, and use learning to improve services. The Trust made adjustments when requested. We therefor will take no further action on the complaint