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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

The Health and Disability Commissioner released a report today finding an ophthalmologist and ophthalmology clinic in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to have checking procedures in place during laser eye surgery.
The ophthalmologist performed laser eye surgery to correct the woman’s vision. During the surgery, the laser failed to cut through the cornea completely. At the end of the procedure, it was discovered that a small-sized treatment pack had been used instead of the medium size that was required for flap formation in the surgery. As a result, the flap size was smaller than expected, and the laser could not complete the side cut of the flap. Since this event, the woman has experienced severe headaches, double and blurry vision, and migraines.
Former Commissioner Anthony Hill was critical that the ophthalmologist chose to complete this part of the surgery manually, rather than abandoning the procedure and allowing the cornea to heal before performing the treatment later.
“[The ophthalmologist] had overall responsibility, as the supervising ophthalmologist performing the surgical procedure, to ensure that the correct treatment pack size had been selected prior to commencing the surgery,” Mr Hill said.
Mr Hill was critical that the clinic did not have any policies or procedures in place to prevent mixing up of the different size packs, or a checking process to ensure that the correct size was used for the procedure.
Mr Hill was also concerned by the lack of notes in the woman’s clinical record about the information provided to her regarding the risks of surgery. He considered the clinic’s consent form was “rudimentary and non-specific in terms of complication”.
The clinic is no longer operating, but Mr Hill recommended that the ophthalmologist undertake further training on documentation and an audit of his informed consent process over the last six months, and apologise to the woman.
The full report for case 17HDC02370 is available on the HDC website.