Failings in care and treatment did not increase loss of vision

What happened

In summer 2012, Mr Y went to the A&E department at the Trust because he had a shadow in his right eye that had begun a couple of days earlier. An emergency nurse practitioner carried out an initial assessment that included taking a history of the symptoms he was experiencing, and testing his vision.

The emergency nurse practitioner contacted a member of the ophthalmology team for advice. The clinical records showed that the emergency nurse practitioner had a discussion with the on–call ophthalmology registrar, who said that Mr Y should be seen by an optician first. The Trust's appointment system shows that staff then made an appointment for Mr Y to be seen in the eye clinic that evening. However, there was nothing documented in the records to explain who had made this appointment or the rationale for it. Furthermore, staff did not tell Mr Y that they had made this appointment for him. Mr Y told us that after his discharge, it was too late to go to an optician and so he went home.

Mr Y's condition worsened overnight and so the next day he went to an eye hospital. Staff found he had high blood pressure and admitted him. He had treatment to control his blood pressure. While in hospital, Mr Y told staff that his vision was deteriorating. After an ophthalmologic review, clinicians felt that Mr Y's visual loss was likely due to anterior ischaemic optic neuropathy (AION), a condition where the small arteries to the optic nerve suddenly become blocked.

Mr Y complained to the Trust about the care and treatment he received in A&E and the ophthalmologist's failure to examine him. He believed that if he had had an appropriate ophthalmologic review, his high blood pressure would have been noticed. This would have allowed clinicians to take action to treat it sooner and his loss of vision could have been reduced.

Mr Y asked the Trust for the name and registration number of the ophthalmologist who gave the advice to the emergency nurse practitioner, so that the General Medical Council (GMC) could consider whether any further investigation was appropriate. The Trust investigated and responded to Mr Y's complaint, but it was unable to identify the doctor concerned. Mr Y was still unhappy with the responses he got and he decided to complain to us.

What we found

We partly upheld this complaint. There were failings in the care Trust staff gave Mr Y when he went to A&E in summer 2012. Staff did not take his blood pressure or put a management plan in place, or tell him about an appointment they had made for him. This meant he did not have an appropriate review.

However, earlier treatment of Mr Y's blood pressure would not have led to a better outcome. His visual loss would not have been reduced if an ophthalmologist had reviewed him when he went to the Trust's hospital. Mr Y's visual loss was caused by AION. Unfortunately, there is no proven treatment for AION itself and no treatment has been shown to improve the visual loss that AION causes.

There were also failings in the Trust's record keeping. The emergency nurse practitioner did not document the name of the ophthalmologist she spoke to in the clinical records department, so there was no record of who gave advice on this case. Mr Y could therefore not know the identity of this person and the GMC did not have the opportunity to consider whether to investigate a complaint about this doctor's fitness to practise.

That said, we considered that our investigation had given Mr Y an independent review of his concerns so he had not been unduly disadvantaged by the Trust's inability to identify the ophthalmologist concerned.

Putting it right

The Trust wrote to Mr Y acknowledging and apologising for the impact of its failings. It also agreed to prepare an action plan to describe what it had done or planned to do, to make sure that it had learnt from its failings in record keeping and its failure to ensure that Mr Y received appropriate medical review.