A string of avoidable communication and admin breakdowns deprived a patient of urgent care when he had an infection which caused him to lose his eye, according to the Health and Disability Commissioner.

The man, who was in his 30s, had surgery in a Wellington hospital on his eye in July 2019 for a condition which meant he needed his cornea regrafted.

Within two days he was in serious pain and fluid was draining from his eye. He was experiencing graft rejection and developed an infection which caused him to lose his entire left eye.

Deputy Commissioner, Dr Vanessa Caldwell, said the then Capital & Coast District Health Board (CCDHB) failed to provide the man with a service of reasonable care and skill – a breach of the code in place to protect patients.

Te Whatu Ora – Health New Zealand may now face a legal challenge over the incident, following a referral from the commissioner.

The man had been discharged the morning after his surgery with a prescription for eye drops but nothing for pain relief and no paperwork to tell him when his follow-up appointment was or what medications to take and when.

When he tried to seek help, the information he had included an inactive phone number.

After two weeks of repeated attempts, he finally reached administrative staff, but they did not understand the urgency of the situation, the commissioner’s report stated. His follow-up appointment was scheduled for five weeks after the surgery at another hospital.

Caldwell said the systems were not fit-for-purpose, outdated and did not allow for timely, appropriate or safe care. The 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, she said.

It was impossible to know if the infection and loss of eye would still have happened if the man had been seen earlier, 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.”

Caldwell criticised the standard of adverse event reporting by CCDHB (now Te Whatu Ora – Capital, Coast and Hutt Valley). A review was not thorough and did not involve all the necessary parties, she said.

Te Whatu Ora – Capital, Coast and Hutt Valley has apologised to the patient and his whānau “for the injury and distress they experienced,” acting chief medical officer Sarah Jackson said.

“No harm or distress to a patient under our care is acceptable. We take patient safety and wellbeing extremely seriously, and acknowledge that we let the patient and their whānau down in this instance.”

Jackson accepted the commissioner’s findings “and will be giving full effect to their recommendations”. Recommendations included an ophthalmology systems audit, improving booking systems and developing guidelines for answering phone calls.

“[W]e identified a number of improvements to prevent something like this happening again – including changing the process for follow-up appointments, improving documentation tools to ensure appointment requests are received and scheduled, and updating post-operative information for patients,” Jackson said.

Stuff asked what the timeline was for these improvements but none was provided. “These improvements have been, or are in the process of being, implemented,” Jackson said.

Te Whatu Ora was referred to the Director of Proceedings, to decide whether any legal proceedings should be taken, due to the “multiple avoidable systemic failures… the significant public safety risk these failures represented” and the ongoing impact on the patient.

Te Whatu Ora would not comment on whether any legal action was going ahead, saying “it would not be appropriate to pre-empt the outcome of that process”.