A man's eye had to be surgically removed after Capital and Coast DHB (CCDHB) provided "poor postoperative care" following surgery, the Health and Disability Commissioner (HDC) said today.
In 2019, the man, who was in his 30s at the time, underwent a penetrating keratoplasty and corneal graft on his left eye and was admitted overnight.
However, when he was discharged the next day, he did not receive a summary outlining postoperative instructions, was given unclear information on when and where to seek help, and did not receive a follow-up appointment one week after the operation, as had been intended.
He contacted CCDHB numerous times over the course of two weeks after experiencing severe pain in his eye, however the preoperative contact information he had been given included an inactive number for the eye clinic.
The man's calls to the DHB were eventually transferred to the eye clinic, but no one answered and there was no service to leave a message. After eventually being put in contact with the booking office, administrative staff did not understand the urgency of the man's situation and scheduled his follow-up appointment five weeks after the operation, at a different hospital.
By the time he was seen by a specialist, he was experiencing immense pain and his eye had swollen so much it was protruding from the socket.
A doctor found the man had experienced a corneal graft rejection and, after a surgery to repair damage to his eye, it was found he had developed an infection that would have been life-threatening had it reached his brain.
Five months later, despite gradual improvements, he eventually underwent a procedure to have his left eye removed.
Deputy Health and Disability Commissioner Vanessa Caldwell found the man was "failed by systems that were not fit-for-purpose, or current, and did not facilitate care that was timely, appropriate, or safe".
She said a series of "avoidable communication breakdowns and administrative shortcomings" robbed the man of the urgent care he needed.
"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.
"However, it is clear 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 was also critical of the internal review CCDHB underwent following the events, saying it was "not thorough and did not involve all the necessary parties to reach a reasonable understanding of the key issues".
CCDHB advised the HDC that it had made several changes since the mismanagement, such as "developing a desk file for administrative staff that includes processes for booking and rescheduling appointments within follow-up time frames, and guidance on answering and escalating telephone calls from patients".
Postoperative information given to patients was also updated and a specialised information card for corneal graft patients was made.
Caldwell recommended further actions from CCDHB, including a written apology to the man, an audit to confirm changes made in ophthalmology discharges, and for it to explore ways to improve its booking system for postoperative follow-up ophthalmology appointments.
Te Whatu Ora was also referred to the Director of Proceedings to determine if any legal proceedings should move ahead.
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