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Avoidable eye removal surgery after failure to treat infection


Organisation we investigated: North Cumbria University Hospitals NHS Trust (the Trust)

Date investigation closed: December 2018


The complaint

Mrs F complained that the Trust’s poor care and treatment of her husband’s eye infection meant that he had to have it removed.

Background

In September 2016 Mr F began experiencing problems with his vision in his left eye. Shortly before his appointment with his GP his vision deteriorated so he visited the GP’s out-of-hours service. He was then referred to the Trust’s Ophthalmology Clinic.

He attended the clinic where he had tests to measure his ability to see objects clearly. The test for his left eye measured six out of 12, which is the minimum standard eyesight required for driving. Mr F was given eye drops to treat inflammation. Four days later, the Trust reviewed Mr F’s vision again and it had dropped to six out of 24, showing that it had worsened. The Trust advised him to continue using the eye drops.

Mr F’s vision in his left eye was measured again in October and it had dropped to six out of 30. He said that his vision in this eye was still blurred so the Trust gave him steroid medication.

The Trust reviewed Mr F’s left eye again in November and found that his vision had got worse. The Trust considered arranging for a diagnostic vitrectomy, a surgical procedure to remove some tissue from the eye, but decided not to. In December, the Trust advised Mr F to continue taking the same steroid medication.

In January 2017, Mr F attended the Trust and was referred to another trust at his request. This organisation found that his left eye was severely inflamed due to a fungal infection and surgically removed it.

What we found

We upheld this complaint. We found that the Trust failed to obtain information about Mr F’s medical history. This would have shown that he had been experiencing bladder infections and episodes of urosepsis, where a urinary tract infection spreads to the bloodstream. Based on this and the fact his eye was inflamed, the Trust should have considered the possibility of an infection.

The Trust did not carry out a diagnostic vitrectomy to find out what was causing the inflammation and sight loss. When it did eventually refer him to another trust to carry out this diagnostic surgery, it was too late and it should have done this sooner.

The Trust should not have prescribed steroids to treat Mr F’s eye because he had a fungal infection which are often made worse by steroids. He was told to continue with this medication for three months, when it was the wrong treatment. This would have been avoided had the vitrectomy been carried out.

The Trust should have changed its approach when Mr F’s symptoms were getting worse. If the correct treatment had been given, while Mr F’s vision may have still deteriorated, it is more likely than not that he would have kept his eye.

The care Mr F received from September 2016 to January 2017 was not in line with General Medical Council guidance, which was a failing.

Putting it right

At our recommendation, the Trust wrote to Mrs F to acknowledge and formally apologise for the failings in her husband’s care and treatment. It also outlined what changes they have made to prevent this from happening again. The Trust made a payment to Mrs F of £1,000 in recognition of the injustice.