NHS patients who underwent eye surgery at a private hospital suffered complications because of an overdose of an antibiotic used during their cataract procedures, an investigation has found.
Private provider Ramsay Health Care, which operates the Mount Stuart Hospital in Torquay, told HSJ that the complications experienced by patients referred to the hospital by South Devon Healthcare Foundation Trust resulted from “process failure and human error”.
South Devon began outsourcing cataracts patients this summer to help clear its waiting list backlog. The trust had originally planned to send 80 patients a month to Mount Stuart.
However, the procedures were halted in July after two patients reported eyesight problems. All 19 patients who had already been treated were then recalled.
In a statement issued today, Ramsay Health Care told HSJ: “An incident occurred at Mount Stuart Hospital on 26 July 2014 that resulted in a number of patients receiving an overdose of an antibiotic during cataract surgery.”
The statement explained that the antibiotic used routinely in cataract surgery is diluted to different concentrations depending on the part of the eye in which it is to be administered. A root cause analysis found that in the Mount Stuart incident the antibiotic had been diluted to a strength inappropriate to the part of the eye in which it was used.
The statement added: “The error occurred in the minor surgical unit of Mount Stuart Hospital and the investigation showed the error to be the result of both process failure and human error.”
A full report of the investigation Ramsay conducted into the incident is due to released later this week.
Both the foundation trust and South Devon and Torbay Clinical Commissioning Group suspended patient referrals to the hospital at the start of September.
A spokesman for the CCG told HSJ it had now lifted the suspension.
The consultant who carried out the procedures was suspended by Mount Stuart during the course of the investigation but has since been reinstated following further training and supervision, Ramsay Health Care said.
The Care Quality Commission carried out an unannounced inspection in response to Mount Stuart informing them of the incident.
Separately, South Devon Healthcare has decided to bring work to clear its cataract surgery backlog back in house.
The trust decided last month that while awaiting the final outcome of the investigation it needed to “revisit options to more quickly increase” its in-house capacity, according to board papers.
The paper states: “The revised plan is to increase the in-house capacity through the recruitment of a locum consultant with training of additional theatre nurses in eye surgery, to support additional theatre sessions.
“These plans are being taken forward with an expectation that from November additional capacity should be available.”
The trust has not ruled out referring patients to Mount Stuart in future.
A trust spokeswoman said: “In order to reduce waiting times for patients, all potential options are being considered.
“Whenever we refer patients to other providers, we carry out quality and safety checks and ensure that they meet current legislative and registration requirements.”
Ramsay Health Care statement (see file attached), trust board papers and HSJ reporting