Barking, Havering and Redbridge University Hospitals NHS Trust

7. Ms A complains about the Trust following a phacoemulsification cataract with intraocular lens (to reduce pressure on her left eye) on 28 July 2023. Specifically, she complains:

• risks were not explained or discussed. Ms A says only success rates were discussed during her consultation and in the information leaflets provided • she did not consent to the consultant making changes to her long-distance vision during the procedure and this was not discussed. The procedure was only to release the pressure in her left eye • her iris was scratched during the procedure.

8. Ms A says the Trust not fully explaining the risks of the procedure meant she could not make a more informed choice.

9. Ms A says because of the procedure and scratching her iris she cannot see or drive as she could before due to the light blurs shining in her eye. This affects her ability to drive at night and collect her children from school and work. Ms A says her eye is still itchy and watery like she has got grit in it. She says these symptoms were not there prior to the procedure.

10. Ms A seeks financial remedy.

11. Ms A is type 1 diabetic (this is a chronic autoimmune condition where the body’s immune system attacks and destroys insulin-producing beta cells) and had glaucoma pressure in both her eyes for several years. She wore glasses for longsightedness for small print only.

12. On 7 June 2023, Ms A attended a clinical appointment. As the pressure in both her eyes (known as intraocular pressure) measured 28mmhg (normal pressure is between 10mmhg and 24mmhg) she was put on the waiting list for phacoemulsification cataract with intraocular lens. This is a minimally invasive cataract surgery that removes the cloudy natural lens and replaces it with an artificial lens to correct vision problems. She was advised to continue with prescribed eyedrops.

13. On 11 July, Ms A had a follow-up appointment. Her pressure in her right eye was 24mmhg and in her left eye 23mmgh. The plan was to continue with the drops and proceed with cataract surgery.

14. On 28 July, Ms A had her cataract surgery. Ms A was given a pre-operative assessment leaflet with instructions on how to look after her eye following the procedure. In her complaint Ms A says she followed all the instructions for four weeks.

15. On 1 August, the Opticians received a referral from the Trust.

16. On 24 August, Ms A had a cataract post-operative assessment at the opticians. Her vision was blurry with a grittiness sensation. An urgent referral was made to the Trust due to anterior chamber cells, irritation of vision and intraocular pressure (fluid inside the eye) being high in the left eye.

17. On 29 September, Ms A had a follow-up appointment at the Trust. On examination her left eye reading was -0.50 (short-sighted), 0.125 CYL (lenses power). Ms A’s pressure remained 28mmhg in her right eye but had reduced in her left eye (the operated eye) to 20mmhg. This is within the normal pressure limits as mentioned in point 14. The Trust said it tried to explain to Ms A her prescription for glasses was much better than before the surgery. At this appointment Ms A requested her care be continued at the Hospital.

18. On 20 February 2024, Ms A attended the optician. She reported symptoms in her left eye, felt gritty, heavy and itchy and her vision was constantly blurry. Ms A said glasses were not helping. She requested a referral to the Hospital for an opinion and possible management.

19. Between May and June 2025, Ms A had several appointments at the Hospital. It was suggested Ms A possibly had a post-operative refractive surprise in her left eye. This is a specific refractive error that occurs after surgery where the intended visual is not met. Information from the Hospital says this is correctable with contact lenses or spectacles, which Ms A did not want. She was keen to have surgery to correct the refractive error. According to information provided by the Hospital this surgery is not available on the NHS.

Risks

23. Ms A complains risks were not discussed. She says only success rates were discussed during her consultation and in the information leaflets provided.

24. During our initial call with Ms A, she said only success rates were explained and how the pressure could damage her eye. She said the leaflets and handouts given just say it is pain free, awake during the procedure and that she may experience blurry vision for three to five days until the eye settles down.

25. Ms A provided us with a copy of the post-operative care leaflet she received. In this leaflet it says that she would experience blurry vision for three to five days. We asked the Trust for a copy of the leaflet outlining the risks of surgery. However, it was unable to supply a copy of the leaflet that was available in 2023.

26. In responding to the complaint, the Trust said post operation Ms A does have a residual corrective error. The Trust explained this normally manifests with blurred vision at distances where the patient was expecting to have good uncorrected visual acuity. The Trust said this is not unusual in this type of surgery and is within the acceptable limits.

27. The recording from the local resolution meeting suggests the Trust did not fully inform Ms A of risks and said advantages including risks and benefits should be discussed with the patient and they would need to check documentation.

28. In the Trust’s final response, it said it became clear during the meeting Ms A’s expectations had not been managed well, and she felt the literature provided and advice offered fell short of providing information around all the risks, complications and possible outcomes which prevented her from making an informed decision.

29. When we investigate a complaint, we first consider what should have happened. We do this by looking at what the relevant clinical guidance says. We then consider what did happen, and whether this fell short of the relevant guidance.

30. GMC guidance discussing benefits and harms says:

• you must give patients clear, accurate and up-to-date information, based on the best available evidence, about the potential benefits and risks of harm of each option, including the option to take no action • it would not be reasonable to share every possible risk of harm, potential complication or side effect. Instead, you should tailor the discussion to each individual patient, guided by what matters to them and share information in a way they can understand.

31. GMC guidance says documents you make (including clinical records) to formally record your work must be clear, accurate and legible. The clinical records should include the information given to patients.

32. On 7 June the clinical records show a discussion took place with Ms A. It does not specifically mention if risks and benefits were discussed. It just notes the information about the pressure of eyes and management plan. The clinical records show us Ms A signed a consent form on 28 July, the day of her surgery. On the consent form it states, ‘serious or frequently occurring risks among others, worse vision together with residual refractive error’.

33. We recognise how important it is for risks and benefits to be discussed clearly with patients. There is no evidence from the clinical records on what was discussed with Ms A around risks and benefits or if this happened. While Ms A did sign a consent form, the Trust acknowledges it did not inform her of the risks and benefits. We consider the Trust did not act in line with GMC guidance. We consider this to be a failing.

34. We have gone on to consider the impact of this in point 50.

Change to vision

35. Ms A complains she did not consent to the consultant making changes to her long-distance vision during the procedure and this was not discussed. She says the procedure was only to release the pressure in her left eye and expected her long-distance vision to remain the same.

36. RCO guidance ‘shared decision making’ says to:

• engage the patient in shared decision making on IOL selection and refractive target, considered the patients preferred refractive outcome, lifestyle and expectations • advise the patient of the inherent limitations of accuracy for achieving refractive targets and inform and actively manage expectations if there is any increased uncertainty for their clinical situation such as small eyes, post refractive procedures • document these discussions and the refractive target clearly in the records.

37. Our adviser gave their view to always correct longsightedness as it makes vision worse for distance and for near. In this case Ms A’s IOL pressure decreased from 28mmhg to 20mmhg but also the refraction was altered as Ms A went from long sighted to emmetropic (20:20 vision) or very slight myopic (shortsighted). Our adviser explained the change in the vision is a direct consequence of the consultant choosing a lens to correct the longsightedness.

38. Saying this, our adviser said there is no evidence in the clinical notes whether refractive outcome (visual outcome) was discussed with the patient and whether this conversation happened or not.

39. It would seem from the local resolution meeting the Trust said Ms A’s preference was to have stayed longsighted in her left eye rather than being slight shortsighted, therefore the visual outcome was not what she was expecting. The Trust said in her case they should have given Ms A the choice to remain longsighted and to have kept her lens longsighted.

40. We recognise how important it is for Ms A to have remained longsighted and that the outcome of the cataract surgery was not what she was expecting. The evidence suggests the Trust did not adequately discuss Ms A’s preference to remain longsighted or clearly document her visual outcome in her clinical records. We consider the Trust did not act in line with ROC guidance and consider this to be a failing.

41. We have gone on to consider the impact of this in point 50.

Iris scratched

42. Ms A complains her iris was scratched during the procedure.

43. The Trust said in the local resolution meeting that this is a side effect of surgery.

44. Cataract surgery studies say iris trauma is a possible complication of cataract surgery. Also, studies suggest complication rates are significantly higher in patients with diabetes.

45. As mentioned in point 30, GMC guidance says it would not be reasonable to share every possible risk of harm, potential complication or side effect.

46. There is no evidence in the clinical records to say if there were any complications during surgery. However, clinical notes provided by the optician mentions ‘left iatrogenic iris atrophy found’ indicating the finding was possibly due to the cataract surgery. Clinical notes from the Hospital also mentions left iris atrophy.

47. As there is no evidence in the clinical notes prior to surgery that Ms A had any iris abnormalities, our adviser gave their view that based on the evidence we can assume the iris was likely affected during surgery.

48. The clinical records also show Ms A was diabetic, and this was listed on the consent form ‘guarded prognosis – glaucoma and diabetic retinopathy’, which the patient signed. Our adviser explained this means Ms A is high risk for all side effects and it is not possible to list these.

49. We recognise complications during surgery can happen and that this was very distressing for Ms A. The evidence suggests Ms A’s iris was affected during surgery. We understand the consent form does not specifically detail iris trauma as a side effect. Given Ms A is diabetic and considered high risk of all side effects, in line with GMC guidance, we consider it would be impractical to list all possible complications. We can also see Ms A signed the consent form. We consider there to be no failing.

Impact

50. When we identify failings, we need to establish whether we can link it to the impact claimed by Ms A.

51. Ms A says the Trust not explaining the risks of the procedure meant she could not make a more informed choice.

52. Ms A says because of the procedure and scratching her iris she cannot see or drive as she could before due to the light blurs shining in her eye. This affects her ability to drive at night and collect her children from school and work. Ms A says her eye is still itchy and watery like she has got grit in it. She says these symptoms were not there prior to the procedure.

53. GMC guidance finding out what matters to a patient says:

• you should explore with patients what risks they would and wouldn’t be prepared to take to achieve a desired outcome, and how the likelihood of a particular outcome might influence their choice

54. We believe that had the Trust explained the risks of the procedure to Ms A and discussed her preference to remain longsighted, she would have been in a better position to make an informed decision. We consider it would have been distressing for Ms A to have found out she was no longer longsighted in her left eye.

55. Our adviser said the change in vision means Ms A will require a spectacle or contact lens correction. We can see from clinical records provided by the Hospital Ms A does not want this. She wants surgery to correct the refractive residual error she now has.

56. We know prior to the surgery, Ms A already wore glasses when she was longsighted. We appreciate the outcome of the cataract surgery was not what she was expecting but spectacles are still an option for her, when taking account that corrective surgery is not available on the NHS, although we acknowledge this is not want Ms A wants.

57. We recognise Ms A had a residual refractive error resulting in blurred or suboptimal vision. We understand how distressing this must have been for Ms A. As this is an accepted risk of cataract surgery and Ms A signed the consent form, we consider this impact is unfortunate but not because of the failings found.

Recommendation

58. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

59. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

What we found

60. Through investigating this complaint, we found:

• the Trust did not discuss the risks with Ms A. This meant Ms A could not make an informed decision • adequately discuss Ms A’s preference to remain longsighted or clearly document her refractive outcome in her clinical records. This led to distress and Ms A unable to make an informed decision on her preferred prescription preference.

What the organisation should do

61. Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.

62. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.

Following this review, we recommend the Trust:

• pay Ms A £550 in recognition of this. We ask the Trust to carry out this recommendation within 45 days of the date of our final report.

1. Ms A complains about Barking, Havering and Redbridge University Hospitals NHS Trust (the Trust) following a phacoemulsification cataract with intraocular lens (to reduce pressure on her left eye) on 28 July 2023. We understand the outcome of the cataract surgery was not what Ms A was expecting and that this was a worrying time for her.

2. We have found failings the Trust did not explain or discuss risks of cataract surgery.

3. We also found the Trust should have discussed Ms A’s preference to remain longsighted in her left eye and recorded this in the clinical notes. There is no evidence they informed her that her vision would change to shortsightedness.

4. We consider, had risks been explained and discussed along with her preferred visual outcome, she would have been in a better position to make an informed decision. We consider this would have been a distressing time for her.

5. We have identified Ms A’s iris was affected during surgery. As this is a known risk of surgery and she signed the consent form, we consider there to be no failing.

6. We have recommended the Trust pay Ms A £550, in recognition of the impact not explaining the risks or discussing her preferred visual outcome had on her.