A practice in the Blackburn with Darwen area

5. Mr T says the Practice failed to refer him for an investigation of a suspected detaching retina in his left eye in May 2022. He later self-referred to a different service (an optician) who he says diagnosed a detaching retina on 6 July 2022.

6. He says this delayed treatment to reattach the retina and restore his vision to normal.

7. Mr T would like an apology and a referral to a service which can treat his eye. He wants reimbursement of any costs incurred, including travel expenses, if this is outside the NHS.

8. Mr T says the Trust delayed operating on his left eye until 26 July 2022. He says this has caused irreparable nerve damage, and the operations he has had have not improved his vision. He says the Trust has been dismissive and has delayed further investigations.

9. He says this is delaying any potential improvement of his eyesight, which is impacting on his quality of life.

10. He wants the Trust to apologise and to assist the Practice to identify someone who can treat his left eye

11. Mr T registered as a new patient with the Practice in May 2022. He says he shared verbal information about an eye consultation from his previous caregiver outside of the UK from March 2022 which suggested he needed follow-on care for a detaching retina. The Practice referred him to ophthalmology and retinopathy a few days later.

12. Mr T expressed dissatisfaction to the Practice about ophthalmology waiting times.

13. Mr T decided to seek further care whilst awaiting an appointment from the Trust. On 6 July, he saw an optician who also made an urgent referral to ophthalmology due to symptoms which he understood to be a detached retina.

14. When ophthalmology reviewed him on 11 and 20 July respectively, it diagnosed a detached retina. Ophthalmology did a corrective procedure on Mr T’s left eye on 26 July 2022, approximately three weeks after the optician’s referral and 15 days after his first ophthalmology appointment.

The Practice

18. 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. We have done this and have seen any signs that something has gone wrong with the Practice’s referral to the Trust’s ophthalmology service. This is because we cannot evidence that the Practice was aware of a concern about a detached retina when Mr T registered as a patient and had a subsequent new patient review. We will now explain this decision in full.

19. Mr T says he told the Practice when he registered that he had been advised of a detaching retina in his left eye before travelling back to England from overseas. The Practice maintain they were not aware of this.

20. The General Medical Council’s (GMC) good medical practice guidelines advise doctors that they must provide a good standard of practice and care. If they assess, diagnose or treat patients, they must:

• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs”.

21. Mr T registered with the Practice and had a new patient medical review in May 2022.

22. During this review, the records show he told the Practice he had lived outside of the UK for many years and had recently moved to the Practice area. He had concerns regarding his ongoing eye medication. He said he had been seen for diabetic retinopathy, and he believed the Practice healthcare assistant was making a referral to follow up this. Blood tests for diabetes were also requested and completed on the same day he had his new patient medical review.

23. Several days later, Mr T was seen in the Practice’s diabetes clinic who completed the diabetes check which included checking his feet, height, weight and blood pressure for example and took his bloods. He was advised to drop off his medical records from his previous care provider when possible. It is documented that he said he would once his house move is settled in a few weeks’ time.

24. A doctor also saw Mr T on this day. He explained to the doctor he had been under ophthalmology for many years and received injections for eye pressures. The return to England had disrupted the treatment. Mr T provided the last two ophthalmology clinic letters, which were added to the referral that the Practice secretaries were handling on instruction of the doctor. The doctor discussed his blood pressure and arranged further blood tests. ulse

25. The urgent referral was sent to the Trust’s ophthalmology service once Mr T provided supporting information from his previous care provider. We noted that the supporting information from the previous care provider was from March 2022. It did not refer to a current concern about retinal detachment. They referred to diabetic retinopathy in both eyes, a historic pars planus vitrectomy (a procedure to remove gel from the eye) following to bleeding in the left eye and retinal detachment in December 2020, and macular oedema of diabetes affecting the right eye. Mr T’s medication was also outlined in the letter.

26. There was a recommendation for a clinical review within this information, but this was suggested for August 2022 for visual acuity (how clearly you see) and optical coherence tomography (OCT) of the macula in both eyes and OCT of the posterior pole under observation of both eyes. These eye tests are to assess vision and retinal health. Both our advisers noted the final page of the previous care provider notes, which are the only notes written in English, refer to high blood pressure and findings which did not appear to clearly relate to the eye information and do not indicate any concerns regarding a detaching retina.

27. Mr T explained he had a further consultation at the hospital in April 2022 before travelling to England, but he does not have any paperwork to evidence this visit or the advice he was given. He says he told the Practice about the outcome of this consultation, which was that he said he was told he had a detaching retina. He believes he should have been sent to either the opticians or the hospital for urgent investigation.

28. We cannot know for certain what advice the previous hospital gave to Mr T before he travelled back to England as he cannot provide any paperwork. On a balance of probability based on our ophthalmology adviser’s advice, we would have expected an ophthalmologist to stress the urgency of a detaching retina to a patient and not to delay treatment. This is because delaying the repair of a detached retina can result in permanent vision loss.

29. After reviewing Mr T’s medical records, we are unable to see any contact with the Practice or the Trust which suggests he was concerned about a detaching retina and the possibility of vision loss. We accept it is possible conversations may have taken place and have not been recorded. We considered if any other evidence was available to corroborate his account, but Mr T was unable to provide any further information.

30. As a result, the only treatment we can say Mr T needed with any certainty was treatment for a diagnosis of diabetic retinopathy. This is a condition caused by damage to blood vessels in the retina due to diabetes. It is not the same condition as a detaching or detached retina. We acknowledge the Trust later diagnosed Mr T with a detached retina on 11 July, but we do not think this supports a failing with the Practice’s referral. This is because there is no evidence to support it should have known about a detaching or detached retina other than Mr T’s retrospective account of events. There is no other evidence to support he raised concerns about a detaching or detached retina with the Practice at the time, such as medical records or information from his previous care provider.

31. The NICE guidance for diabetic retinopathy management and monitoring says treatment for diabetic retinopathy should be started within four weeks of being offered treatment if possible, or within six weeks if four weeks is not possible. Our ophthalmology adviser confirmed the Practice sent an urgent referral to the ophthalmology service, but it would expect an ophthalmology team to ordinarily treat a request of this nature as non-urgent (within four to six weeks) as per the NICE guidance.

32. In conclusion, we have considered the available evidence, and we are unable to see that anything went wrong with the Practice’s referral to ophthalmology. We appreciate Mr T says he mentioned to staff that he had a detaching retina, however there is no record of this conversation with any of the different staff he discussed his needs with, at the Practice. Mr T was also unable to produce medical records from his past care provider that evidenced he was told about a detaching retina. However, other issues regarding his eye care are clearly documented and was acted upon, such as the referral being made to resume his medication for diabetic retinopathy as his previous care provider recommended.

33. We recognise the significant impact of sight loss and the resulting impact on his quality of life. We thank Mr T for taking the time to share his concerns about the Practice despite the challenges he faces.

34. We will now consider the complaint about the Trust.

East Lancashire NHS Foundation Trust

35. As with the complaint about the Practice, we have looked at whether there are signs the Trust has got something wrong with Mr T’s treatment. We have not seen signs of anything going wrong with the type of treatment Mr T was offered to correct the detached retina. We will now explain this in full.

36. Mr T’s complaint is about the Trust’s delay to investigate and treat a detached retina and the associated impact of this.

37. The Trust maintains it offered appropriate treatment to Mr T. In a local resolution meeting, it explained what Mr T’s diagnosis was, including an explanation of what may have been described as ‘a crease’, and what treatment was offered to him. It says if the Practice referred him for a detached retina, he would have received surgery within 24-48 hours if the macular was still attached. It explained if the macular is off and subretinal fibrosis has started to happen, this is a chronic retinal detachment and the urgency reduces. This is what happened in Mr T’s case.

38. The Trust told Mr T in May 2023 that his left eye was unlikely to improve. We understand this was upsetting to Mr T, and he was keen for further investigations and treatments to be tried. The Trust offered a second opinion from another NHS consultant. He continued to have ongoing eye treatments for diabetic macular oedema (DMO, a condition where high blood sugar damages retinal blood vessels, causing them to leak fluid into the macula).

39. The Trust was first informed of concerning symptoms on 6 July when Mr T’s optician sent an urgent referral to it.

40. At his first appointment with ophthalmology on 11 July, Mr T was diagnosed with a macular-off inferior retinal detachment (when the retina is detached from the centre of the eye, causing vision loss).

41. We note that the optician’s referral was not confirmation of a detaching or detached retina, only symptoms indicating the need for urgent further investigation. The optician said there was ‘a rapid deterioration in vision LE (left eye) over last three weeks’ and ‘an exudative detachment with fluid between RPE (retinal pigment epithelium, a pigmented cell layer that maintains retinal health) and retina’, which they said they were ‘not sure if due to diabetes and RE (right eye) cystoid macula oedema’. Our ophthalmology adviser explained an exudative detachment is a different condition to rhegmatogenous retinal detachment (RRD) but they present in a similar way and there are different care pathways. An urgent further investigation was required to diagnose the problem.

42. There was a five day wait for diagnosis, which was followed by a wait of just over two weeks for treatment for surgery. This is because the Trust explained that the chronic detachment and the delay in seeking treatment reduced the urgency of the treatment.

43. Our adviser also explained some mild cases of retinal detachment can be treated non-surgically with oil or eye drops, whilst more chronic cases require surgical intervention, such as a vitrectomy. Vitrectomy is a surgical procedure to remove the vitreous gel from the eye whilst problems can be repaired in the eye. It is then replaced with a clear fluid, gas bubble or silicone oil to help heal the eye. Early intervention at the onset of symptoms is crucial for protecting the centre of the eye (the macular) which is crucial for vision.

44. The recommended treatment for Mr T was a vitrectomy, because his problem was considered ‘chronic’ on 11 July and he had reported deterioration in his eyesight for three weeks at this appointment.

45. This information about the onset of symptoms would be relevant in the Trust assessing the urgency of the treatment. A key factor is whether the macular is ‘on’ (detaching but not fully detached) or ‘off’ (detached). Our ophthalmology adviser explained a rule ophthalmologist’s follow is if the symptom onset was 24 hours ago, surgery should also be within the next 24 hours; if the patient had onset of symptoms a week prior, surgery should be within a week, and so on. This is supported by the IJO and BMJ guidance, which both explain the reduced chance of successful treatment the longer the delay between symptom onset and treatment. Our adviser explained most hospitals follow a two-week criteria for cases not deemed ‘same-day casualties’ because of this. Mr T was not a same day casualty because his eyesight had deteriorated over a long period and was a full detachment case.

46. We are satisfied the Trust considered this when considering how best to proceed. It explained its rationale to Mr T, and this rationale is supported by the guidance our ophthalmology adviser explained to us.

47. We did note a short and potentially avoidable delay between his first ophthalmology appointment on 11 July and 20 July when the Trust escalated Mr T to a specialist team. Ideally, he would have been treated within seven days of his first ophthalmology appointment. Our adviser said this may be due to a Trust policy.

48. We considered whether it is proportionate to explore this further. Given the length of time Mr T had been concerned about a gradual reduction in his eyesight, he had likely already missed the optimal window for treatment much earlier than 11 July. By this date, Mr T’s detachment was described as ‘chronic’ and was a bad detachment. It was not inoperable, but the likelihood of success was already reduced.

49. We also see that at his first ophthalmology appointment, Mr T complained of his eyesight ‘going blurry over the past few months’. At the following consultation he referred to gradual deterioration of vision in his left eye over two years. He had also complained of reduced vision for three weeks to the optician on 6 July, which was documented on the referral, and we know he asserts that he was told by a consultant that he had a detaching retina in April when living abroad. As the likelihood of successful treatment would have reduced over this time, it is in line with the BMJ and IJO guidance that Mr T’s procedure was no longer considered urgent. We understand Mr T is aware of this as this was the basis for his complaint about the Practice.

50. We cannot know if the operation would have been successful if performed sooner. By 6 May when Mr T first approached his GP, it was already at least six days from when he says he was advised of a detaching retina at the hospital abroad in April, if not longer. Mr T has not provided the exact date of this consultation, however the IJO review shows diminished outcomes after only four days’ delay.

51. On a balance of probability, it is just as possible that he would have had the same or similar outcome had he been operated on sooner following the initial ophthalmology appointment on 11 July. When viewed in the context of the onset of symptoms being from at least April and the Trust not knowing about this until July, we are unable to attribute a missed opportunity for a better outcome to any of the Trust’s decision-making about treatment.

52. For this reason, we have decided not to further investigate this complaint. We accept there are limitations to what treatment was able to achieve for Mr T given the circumstances, and we are sorry to hear his eye is now unlikely to improve. We also appreciate the time he has taken to share his concerns despite the additional barriers he faces from vision loss, which we recognise has also had a significant impact on his quality of life.

1. We have carefully considered Mr T’s complaint about the Practice and East Lancashire NHS Foundation Trust.

2. We have not seen signs that anything went wrong with the Practice’s referrals for a retinopathy screening and ophthalmology. This is because we have not seen evidence which confirms the Practice should have known about concerns about a detaching or detached retina.

3. We have not seen signs that anything went wrong with East Lancashire NHS Foundation Trust (the Trust)’s treatment of Mr T’s presenting eye problem. This is because the Trust followed the relevant guidelines when deciding how and when to treat Mr T’s detached retina.

4. We appreciate it is distressing to experience vision loss, and we are sorry to hear Mr T has been told his chances of further recovery are limited.