Articles and Case Studies

When Things Don't Go as Planned

03 Apr 2012

by Yvonne Baldwin

Claims Manager, Yvonne Baldwin, reviews a case that highlights what can go wrong when aspects of a patient’s management are delegated to practice staff.

Case history

On 15 November 2010, an 81 year old male patient consulted an ophthalmologist (the surgeon) for assessment and treatment of bilateral cataracts. The patient was diagnosed as having extensive cataracts which were causing significant disturbance, such that his optometrist was unable to give him clear vision with spectacle correction alone.

The surgeon informed the patient of the non-surgical and surgical options available to him. The non-surgical options included continuing to wear glasses and accepting blur and loss of contrast sensitivity. Surgical options included the implantation of either a monofocal or multi-focal lens, as the patient was a suitable candidate for either lens type.

The surgeon informed the patient of the issues and special risks associated with multi-focal lenses. The patient did not like the prospect of wearing reading glasses post-operatively, and elected to have multi-focal lenses inserted.

At the conclusion of the consultation, the surgeon dictated a letter to the referring general practitioner in which he set out the proposed treatment plan. The patient then saw the surgeon’s secretary to have the surgery scheduled and to sign the consent form. When obtaining a blank consent form, the secretary inadvertently grabbed a “Consent
for Monofocal Lens Insertion” form, not the “Consent for Multi-focal Lens Insertion” that the surgeon had requested.

On 18 November 2010, the patient was scheduled to undergo a right cataract extraction and insertion of intraocular lens. The surgical team performed a “timeout”.

A check of the booking sheet, theatre list and consent form signed by the patient all indicated that a monofocal lens was to be implanted.

The surgeon reviewed the patient post-operatively in his rooms on 19 November 2010. His right eye corrected to 6/9 vision, the lens was central and the cornea was clear. The patient’s vision was slightly myopic, which was appropriate for a person of the patient’s age as he mainly needed intermediate distance vision.

During the consultation, the surgeon told the patient that the lens insertion had proceeded uneventfully and he was pleased with the visual acuity the monofocal lens provided. At this point, the patient asked why a multi-focal lens had not been implanted. When the surgeon checked the medical records and noted that the letter to the general practitioner clearly stated that a multi-focal lens was to be inserted, he realised that an error had occurred. The surgeon apologised to the patient for the mistake.

Although the patient had good post-operative visual acuity, he was angry that the surgeon had not implanted the lens he had requested. When the patient demanded that the surgeon remove the monofocal lens and replace it with a multi-focal one, the surgeon explained that although he had inadvertently implanted the “wrong” lens, the result of lens exchange was unpredictable and as the patient had good post-operative visual acuity, he should leave well enough alone.

Although clearly dissatisfied, the patient agreed for the monofocal lens to remain in situ.

On 30 November 2010, the surgeon performed a left cataract extraction and insertion of a monofocal intraocular lens. The surgery proceeded without incident.

On 1 December 2010, the surgeon reviewed the patient and noted he had good post-operative visual acuity and that both eyes were working well together.

On 17 January 2011, the surgeon received a letter from the Australian Health Practitioner Regulation Agency (AHPRA) informing him that the patient had made a complaint. The letter informed the surgeon that the following aspects of his patient management were to be investigated:

  • That he gave the patient incorrect advice in the pre-operative consultation because he implanted a different lens in the right eye to what he said he would.
  • That he performed inappropriate surgery on the patient as he implanted a lens other than what the patient had requested.
  • That he failed to inform the patient of the error and it only came to light when the patient queried the nature of the surgery he had undergone.
  • That he was unable to communicate clearly with patients, given that he implanted a different lens to what the patient had requested.

The Health Complaints Entity for each state or territory is:
Human Rights Commission
Health Care Complaints Commission
Health & Community Service
Complaints Commission
Health Quality & Complaints
Health & Community Services
Complaints Commission
Health Complaints Commissioner
Office of the Health Services
 Health & Disability Services
Complaints Office

AHPRA invited the surgeon to provide a written response to the patient’s complaint within 14 days.

The surgeon, with the assistance of MDA National, provided a comprehensive response to AHPRA in which he addressed the various issues raised by the patient.

In his written submission, the surgeon explained how the error had occurred and the steps he had taken to ensure that it did not happen again, including ensuring that only he completed and witnessed the patient’s consent. The surgeon also reiterated his apology to the patient.

This case highlights what can go wrong when aspects of a patient’s management are delegated. It would have added very little time to the consultation if the surgeon had completed the consent form with the patient.

AHPRA sought the surgeon’s consent to provide a copy of the response to the patient, which the surgeon agreed to.

Several weeks later, the surgeon received a further letter from AHPRA informing him that although the patient understood the explanation he had provided, he was still angry and felt aggrieved because:

  1. he had not received the lens he had requested
  2. the surgeon had refused to remove the monofocal lens and replace it with a multi-focal lens.

As the complaint was unresolved, AHPRA reviewed the complaint in conjunction with the Health Complaints Entity (HCE) in the surgeon’s particular state/territory.

The HCE considered that the surgeon’s response was both comprehensive, honest and compassionate, and as the surgeon had taken steps to minimise (and hopefully prevent) such a mistake from recurring, decided that no further action needed to be taken. The HCE proceeded to close the complaint.


This case highlights what can go wrong when aspects of a patient’s management are delegated. It would have added very little time to the consultation if the surgeon had completed the consent form with the patient and witnessed the patient’s signature.

Seek advice early

Members are encouraged to seek advice from MDA National if they receive a complaint from or about a patient. You can contact our Medico-legal Advisory Service 24/7 on 1800 011 255 or email

The case also exemplifies what can happen when a patient is dissatisfied with an aspect of his or her treatment, even in circumstances when the treatment has been successful.

When a notification/complaint is made about a health system or health service provider, AHPRA and the relevant HCE confer with each other and ensure that each notification is investigated by the appropriate agency.

By Yvonne Baldwin
Claims Manager (Solicitor)

Anaesthesia, Dermatology, Emergency Medicine, General Practice, Intensive Care Medicine, Obstetrics and Gynaecology, Ophthalmology, Pathology, Practice Manager Or Owner, Psychiatry, Radiology, Sports Medicine, Surgery


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