A young man’s eye had to be surgically removed after he suffered an infection and loss of vision amid “poor postoperative care” from his health provider.
Health and Disability Deputy Commissioner Dr Vanessa Caldwell found the man had been “failed by a system that was not fit-for-purpose, or current”.
Capital and Coast District Health Board (CCDHB), now Te Whatu Ora Capital, Coast and Hutt Valley, did not facilitate care, in the man’s case, that was timely, appropriate or safe, Caldwell ruled in a report released today.
She found CCDHB breached the Code of Health and Disability Services Consumer’s Rights by providing “poor postoperative care” following the man’s eye surgery.
Her report sets out the background which led the man’s mother to file a complaint with the Health and Disability Commissioner.
In 2011, the man was diagnosed with keratoconus, a condition in which the cornea thins and bulges outward. Six years later, he successfully received surgery to replace the cornea on his right eye and the same procedure on the left eye was planned for 2019.
In July of that year, he underwent the surgery at a Wellington Hospital but within three days he was in serious pain and continued to feel unwell.
The man, in his 30s at the time, did not receive a discharge summary outlining the operation or postoperative instructions following eye surgery, and the written information he did receive did not give clear information on when and where to seek help.
He also did not receive a follow-up appointment one week after his surgery, as had been intended.
The man attempted to obtain medical attention. However, the preoperative information provided on who to contact in the event of an emergency differed from the post-operative information and included an inactive telephone number.
His calls to CCDHB were transferred to the Eye Clinic, but no one answered, and there was no answer phone service.
When he was eventually connected with the booking office, after two weeks of repeated calls, the administrative staff did not understand the urgency of the situation.
His follow-up appointment was scheduled for five weeks after the date of surgery at another hospital.
Six days out from his appointment, the man had returned to his residence in another region and was experiencing immense pain. His eye had swollen and was “protruding from the socket”.
He took himself to an optometrist who contacted an ophthalmologist at the local DHB, and an appointment was made for him that day.
The consultant ophthalmologist diagnosed a corneal graft rejection and phoned CCDHB to discuss treatment.
The CCDHB brought forward the man’s follow-up appointment and he was seen in its Emergency Eye Clinic the next morning, then admitted under the Ophthalmology Service around midday for management of endophthalmitis and an infected corneal graft.
That evening, he underwent surgery to repair the damage but the following day he was told there was a poor prognosis for the eye. In February 2020, his eye was surgically removed.
In her report, Caldwell said a series of avoidable communication breakdowns and administrative shortcomings deprived the man of the urgent advice and care he needed, despite his repeated attempts to seek help.
“I acknowledge that it cannot be known whether he would have gone on to endure the immense pain, severe infection, and loss of his left eye that occurred, had he received a timelier postoperative review.
“However, it is clear he did not receive the necessary and expected opportunity to identify and manage any postoperative complications at one week following his surgery, as would be expected.”
Caldwell was also critical of the standard of adverse event reporting by CCDHB.
She said after an event like the one at hand, an internal review could be useful to understand what went wrong and what was needed to put in place to ensure it did not happen again.
“The review that was undertaken in this case was not thorough and did not involve all the necessary parties to reach a reasonable understanding of the key issues.”
CCDHB advised HDC that, since the events, several changes have been made, including developing a desk file for administrative staff that included processes for booking and rescheduling appointments within follow-up time frames, and guidance on answering and escalating telephone calls from patients.
The postoperative information given to patients was also reviewed and updated and a card was developed for corneal graft patients, advising which symptoms require urgent attention and where to seek help.
But Caldwell recommended further actions, including that CCDHB provide a formal written apology to the man, conduct an audit to confirm that ophthalmology receives discharge summaries and timely follow-up appointments, and look at ways to improve the booking system for postoperative follow-up ophthalmology appointments.
Te Whatu Ora was also referred to the Director of Proceedings to decide whether any legal proceedings should be taken.
Tara Shaskey joined NZME in 2022 as a news director and Open Justice reporter. She has been a reporter since 2014 and previously worked at Stuff where she covered crime and justice, arts and entertainment, and Māori issues.
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