Source: Health and Disability Commissioner
The breaches concern their care of a woman who went on to lose sight in her right eye because of retinal detachment.
The woman presented to the clinic for a routine eye examination and while there, reported black or grey specs in her vision. She was examined, prescribed reading glasses and asked to return in two years’ time. She returned 10 months later, reporting dark, blurred vision. Again, she was examined, retinal images were taken and she was prescribed eye drops. She returned five days later, reporting no improvement, and a ‘stingy’ right eye.
On further examination it was noted that her visual acuity had reduced slightly in the last five days, so a non-urgent referral to an eye specialist was made. The specialist diagnosed a retinal detachment and scheduled corrective surgery. Unfortunately, the woman underwent two unsuccessful surgeries and permanently lost vision in her right eye.
Dr Vanessa Caldwell was critical that a retinal examination was not performed at earlier presentations to the optometrists when there were clear indicators this should have occurred. The failure to assess the information available to them which should have indicated a retinal examination was needed, and the non-urgent referral resulted in a delayed diagnosis of the retinal detachment. She was also critical of their poor documentation and commented that the note taking of one of the optometrists fell far short of the required professional standards.
Since the events, both optometrists have undertaken a range of actions to improve their practice. The clinic has also made changes to its communications practices and updated its technology to strengthen its diagnostic testing capability.
Dr Caldwell made a range of recommendations to both optometrists and the eye clinic including undertaking an audit of files where retinal photography has been performed to examine if clinical observations are up to the required professional standards.
