The following case is fictitious but based on the types of calls we receive to the MDU advice line.
The scene
During a patient's procedure for cataracts, a consultant ophthalmic surgeon inserted an incorrect lens, based on the biometry for the other eye.
When the patient returned to clinic for review, her vision was very blurry and the optometrist explained that the surgeon would need to see her again. The consultant reviewed his records and immediately realised what had happened. Thinking it was best to break the news to the patient in person, he dictated a letter asking her to return for a further appointment.
Meanwhile, the patient sought an urgent second opinion after feeling fobbed off by the clinic. After being told that her replacement lens had the wrong refractive power, the patient immediately contacted the trust to complain.
The treating consultant was called to a meeting with the medical director, who was angry that the consultant's response had not followed the trust's duty of candour policy. He warned him to expect a disciplinary investigation and threatened to report him to the GMC.
The meeting left the consultant shaken and he called the MDU for advice.
MDU advice
The MDU's adviser accepted that the consultant had wanted to talk to the patient in person about what had gone wrong, to offer a personal apology and explain he was going to rectify the error.
The problem was that he had not called her immediately and had delayed reporting the incident, which meant he had now been overtaken by events. The consultant would now need take steps to meet his professional obligations and show he had learned from what had happened.
Using the wrong lens during a cataract operation would constitute a notifiable patient safety incident under the statutory duty of candour, because the patient would experience an impairment of sensory functions and require additional treatment.
In addition, use of the wrong implant would be considered as a never event by NHS Improvement, and should be logged and reported through national reporting systems.
If this had not already happened, the consultant needed to report the adverse incident, ensuring it was logged as a never event and was being appropriately managed under duty of candour procedures.
The statutory duty of candour applied to the organisation and not individual staff, but he would be expected to co-operate; for example, by acting as the trust's representative in meetings with the patient, saying sorry to the patient, offering reasonable support and contributing to further inquiries. This aligned with his own ethical duty to be honest and open with patients about errors and to apologise.
In addition, the consultant was also advised to liaise with the complaints department to investigate and respond formally to the patient's specific concerns.
The treating consultant was called to a meeting with the medical director, who was angry that the consultant's response had not followed the trust's duty of candour policy.
The outcome
The consultant immediately acted on the MDU's advice to ensure the adverse incident was being appropriately managed, and cooperated with the trust's duty of candour procedures.
As part of the process, he met the patient and he apologised to her for the error and the poor communication. He also arranged for her to receive remedial treatment by another senior ophthalmic consultant. She accepted his apology but decided to receive treatment at another hospital.
The consultant also wrote a detailed statement for the trust investigation based on his medical records, which expressed his regret for not acting as soon as he was aware of what had gone wrong. The trust accepted he had not deliberately tried to cover up the incident and had shown insight into how to improve his practice. The consultant eventually accepted a written warning but was not reported to the GMC.
This case study first appeared in the 2021 edition of Cautionary Tales.
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