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.
While information leaflets can be a useful way of summarising information about a procedure, they should be used to support full discussion with the patient about the risks and benefits of a procedure and any alternatives. GMC Guidance on Consent (2008), para 51, says: You must use the patient's medical records or a consent form to record the key elements of your discussion with the patient. This should include the information you discussed, any specific requests by the patient, any written, visual or audio information given to the patient, and details of any decisions that were made.
This guidance was correct at publication 16/12/2010. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.