Following the Health Service Investigation Branch’s (HSIB) recent report on the failures relating to the timely monitoring of glaucoma, this article explains the role Moore Blatch played in highlighting this issue nationally.
Moore Blatch received instructions from a mother of three who had lost her sight as a result of delays within the glaucoma monitoring clinic at University Hospital Southampton NHS Foundation Trust.
Sight loss at any time is devastating; to lose one’s sight while caring for young children is a catastrophe. Our client was pregnant at the time of her visual decline; she gave birth to her third child in 2017 and has never seen her daughter’s face.
As part of the process of obtaining medical records from the Trust, we requested all risk management documentation. It is fundamental to Moore Blatch’s work that as well as getting the best result for our individual client we endeavour to address the structural issues that cause the problem in the first place.
The Trust’s risk management papers revealed that a Serious Incident Report had identified our client and 15 other people who had suffered avoidable sight loss as a result of delay. Patients had not been given proper follow-up appointments, and there was no system in place for prioritising patients at particular risk. The system seems to have broken down because of a booking system unable to cope with the sophistication of the task, in the context of a service with major capacity issues.
Moore Blatch referred the case to the HSIB, which is tasked by the Government with conducting independent investigations into patient-safety concerns in NHS-funded care. We asked HSIB to consider looking at ophthalmology delays across the country and it agreed to undertake a full investigation.
In October 2018 the Health Service Journal broke the story after whistle-blowing by junior doctors at the Trust, reporting that at least 7,000 patients with conditions such as glaucoma had not been followed up correctly, often with very serious consequences – including, as in our client’s case, blindness.
The Royal College of Ophthalmologists pointed to similar problems at a national level due to a shortage of Consultant staff. The story was picked up in the Daily Telegraph and in the local press.
We published our concern in a November 2018 press release calling for greater support for ophthalmology patients from across the Isle of Wight and the South East because we believed our client’s injury reflected a widespread problem.
Glaucoma is a serious condition in which the pressure inside the eye can increase to a level that causes permanent damage to the optic nerve. It is one of the main causes of irreversible blindness in the UK. Patients with glaucoma need to be closely monitored so that treatment can be provided to lower the pressure inside the eye as necessary.
In our client’s case, there was a delay in follow-up at the Trust’s glaucoma clinic of some 11 months between 2016 and 2018, as a result of which she lost the opportunity of surgery that would have preserved some of her sight and prevented her from going blind.
HSIB published its report in January 2020. It found that there is inadequate capacity in the Hospital Eye Service and made seven specific recommendations to bodies including the Royal College of Ophthalmologists, NHS England and NHS Improvement, NHS Digital and the International Glaucoma Association, requiring responses within 90 days.
Moore Blatch welcomes the investigation and the HSIB recommendations, but parts of the report make for somewhat depressing reading. There are already clear guidelines from the National Institute for Health and Care Excellence (‘NICE’) on the management of glaucoma, with specified time intervals for follow-up appointments. As long ago as 2009, the National Patient Safety Agency (‘NPSA’) highlighted cases in which cancelled or delayed follow-up for glaucoma patients had led to avoidable harm and made recommendations including a system to flag up the clinical priority of specific appointments. Neither the NICE guidelines nor the NPSA report had been sufficient to keep our client, or many other patients, safe.
It is of course appreciated that there are immense financial constraints within the NHS, and that NHS Trusts are only too aware of the impact that has on the services they deliver, but there are real life consequences. Our client would gladly return the financial compensation she has received in return for the vision she would have had with proper care. Blindness is devastating for an individual and their family.
Our client hopes, and we at Moore Blatch hope, that her case and the HSIB investigation it has prompted will be the wake-up call that brings about real change in the standard of our national ophthalmology services.