The Health and Disability Commissioner (HDC) has found Capital and Coast District Health Board (CCDHB) in Wellington provided poor postoperative care following a man's eye surgery in 2016, causing him to go blind and have one of his eyes removed.
It found CCDHB (now Te Whatu Ora Capital, Coast and Hutt Valley) breached the Code of Health and Disability Services Consumers' Rights when the man, in his 30s, was in their care.
The man did not receive a discharge summary outlining the operation or postoperative instructions following eye surgery, and the written information he did receive did not give clear information on when and where to seek help.
The HDC found the man had not received a follow-up appointment one week after his surgery which had been intended.
After experiencing serious pain and eye fluid discharge, the man sought emergency help which was provided to him, however after repeatedly calling the CCDHB phone number provided he discovered it was inactive.
He was then transferred to the eye clinic, but no one answered and there was no answerphone service.
When the man was eventually connected with the booking office following two weeks of repeated calls, staff did not understand the urgency of his situation despite him explaining his painful conditions.
His follow-up appointment was scheduled at another hospital, five weeks after the date of his surgery. During that time the man experienced corneal graft rejection and developed a serious infection, resulting in lost vision and the removal of his left eye.
HDC Deputy Commissioner Dr Vanessa Caldwell found CCDHB breached Right 4(1) of the Code, for not providing the man with reasonable care and skill.
Dr Caldwell said the man was failed by systems that were not fit for purpose and did not facilitate timely, appropriate or safe care.
She said a series of "avoidable communication breakdowns" and "administrative shortcomings" deprived the man of the urgent advice and care he needed, despite his repeated attempts to seek help.
"I acknowledge that it cannot be known whether he would have gone on to endure the immense pain, severe infection, and loss of his left eye that occurred, had he received a timelier postoperative review," she said.
"He did not receive the necessary and expected opportunity to identify and manage any postoperative complications at one week following his surgery, as would be expected," she said.
CCDHB has since advised the HDC that several changes have been made - including the processes of booking and rescheduling appointments within follow-up time frames, and guidance on answering and escalating phone calls from patients.
The postoperative information was updated, advising patients which symptoms require urgent attention and where to seek help.
CCDHB advised that it sincerely apologised to the man and his family, that its systems and processes were not sufficient, contributing to an unnecessary delay in his care which resulted in the complete loss of his left eye.
Te Whatu Ora has been referred to the Director of Proceedings to decide whether any legal proceedings should be taken.
