A consultant ophthalmologist, an MDU member, examined a patient who had reduced vision. The patient had a history of myopia. A cataract was found on examination and the member recommended cataract surgery with a lens implant, to be carried out under local anaesthetic.

According to the records, the patient was given an information leaflet pre-operatively. The complications listed in the leaflet included infection, haemorrhage, clouding of the cornea, glaucoma and retinal detachment.

The patient underwent the procedure which itself was uneventful.

Post-operatively, the patient suffered a retinal detachment and his care was transferred to another ophthalmologist. The patient later made a claim against our member, claiming he had specifically asked whether or not there was a risk of retinal detachment and was told there was not. He also complained that he had experienced considerable pain during the course of the cataract surgery.

The MDU's response

The MDU obtained a detailed factual account from the member. He stressed that it was his usual practice to discuss with the patient, among other things, the possibility of complications arising from surgery. An expert opinion was obtained from a consultant ophthalmologist. The expert report indicated that the member's position was weakened by the lack of documentation of any discussion about retinal detachment, including the lack of detail on the consent form for the cataract surgery. The expert did, however, note what the member had said in relation to his normal practice and he also noted that the patient had been given a detailed information leaflet.

The expert found it difficult to accept the allegation that the doctor had denied any risk of retinal detachment, particularly since he documented the patient's history of myopia.

The second allegation put forward was that of pain during the course of the surgery. There was no evidence of this among the papers provided to support the claimant, and it was also documented by the anaesthetist that the patient 'appeared comfortable throughout' the procedure.

The expert concluded that there was no evidence of any deficiency in the care provided by the member, and this included the cataract surgery itself.

No formal letter of claim was ever served. The MDU wrote to the claimant's solicitors to let them know that we had obtained a supportive expert opinion in this matter. In the event, the claim was discontinued.

Learning point

While information leaflets can be a useful way of summarising information about a procedure, they are not an alternative to a fully documented discussion with the patient about the risks and benefits of a procedure and any alternatives. The GMC's guidance, Decision making and consent (2020), paragraphs 50 & 51, say:

"Keeping patients’ medical records up to date with key information is important for continuity of care. Keeping an accurate record of the exchange of information leading to a decision in a patient’s record will inform their future care and help you to explain and justify your decisions and actions.

"You should take a proportionate approach to the level of detail you record. Good medical practice states that you must include the decisions made and actions agreed - and who is making the decisions and agreeing the actions – in the patient’s clinical records. This includes decisions to take no action."

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