An eye surgeon waited until after he got back from his two-week break to tell his patient there was a major complication during her failed eye transplant operation.
During surgery, which took place in February 2018, the ophthalmologist discovered the eye donor had undergone laser surgery which meant the eye was "unsuitable" for a transplant. He went ahead with the operation anyway.
But due to the complication, the 41-year-old female patient's distorted vision did not improve.
The doctor has been found in breach for failing to promptly tell the woman of the devastating issue, a Health and Disability Commission (HDC) report has today revealed.
The HDC - who's purpose is to promote and protect the right of consumers - investigated the issue after the woman made a complaint.
During the investigation, the doctor told HDC he wanted to wait until the woman had a support person with her before he explained fully what had happened.
He then went on leave and did not see the woman again until two weeks later, which was when he disclosed the issue, the report said.
Health and Disability Commissioner Anthony Hill criticised the surgeon, saying it was unreasonable to decide that disclosure would cause her unnecessary stress, and she should have been told much sooner.
The ophthalmologist decided to continue with the surgery using the donor tissue because there was a possibility that it could work successfully, and he believed that waking the woman up at this stage would have risked her losing the eye permanently, the report said.
Hill said the ophthalmologist's decision to continue with the surgery after was reasonable, but that by failing to disclose the issue to the patient until two weeks later was a breach of the Health and Disability Services Consumers' Rights.
The commissioner recommended the ophthalmologist apologise to the woman for the delayed disclosure and that he review HDC's "Guidance on Open Disclosure Policies".
Hill also advised the District Health Board, where the surgeon worked, to consider updating its open disclosure policy, to include guidance on what to do when a lead clinician is not available.
Due to the issues the case raised regarding the screening of corneal tissue for previous laser surgery, the commissioner recommended that the Ministry of Health consider asking clinics to include this risk in their consent process.
The Eye Bank were also told by Hill to consider the issues identified in the report and to look at trialling the use of machines to test for prior laser surgery in donated corneas.
Since the failed surgery, the doctor told HDC he had discovered a "simple and reliable way" to check if the donor eye tissue had undergone laser surgery. He believed it would "eliminate the problem" and would publish his method in a refereed medical journal to
make it widely known.
The DHB told HDC that no changes had been made to the service it provided as currently there was no reliable method of identifying which donors had had laser surgery.
An Eye Bank spokesperson told the HDC there were many difficulties when screening for
suitable eye tissue, as eye donors were always deceased persons.
"Therefore, post-mortem medical history screening relies on both obtaining documented medical history, and interview of a donor's close relative, and possibly [general practitioner] to fully ascertain presence of exclusionary criteria, or high-risk factors due to lifestyle practices.
"It is inherently second-hand and not able to be obtained from the donor themselves. In both of these areas, it can be difficult for [the] Eye Bank or staff performing such screening, to ascertain with any certainty whether the donor had previous refractive surgery.
"Donor history screening is only as effective as the knowledge able to be determined."