Plan v El-Amir & Anor

In a clinical negligence claim, a doctor must obtain informed consent by explaining material risks, the realistic benefits of the proposed treatment and reasonable alternatives, assessed in the circumstances of the particular patient. Consent is inadequate where the patient is not told that the procedure is unlikely to achieve the outcome sought and carries significant risks to the patient’s better eye.

Where raised intraocular pressure follows eye surgery, urgent investigation and treatment are required. On the facts, failure to perform peripheral iridotomy within 48 hours of dangerously raised pressure fell below the required standard and materially contributed to permanent optic-nerve damage.

The claimant brought a negligence claim against an ophthalmic surgeon and the hospital where surgery was performed. The claim concerned insertion of an intraocular lens implant in the claimant’s right eye in August 2013.

The claimant alleged that the surgery was undertaken without informed consent and that the surgeon subsequently failed to diagnose and treat raised intraocular pressure promptly. The hospital entered administration and the claim against it was withdrawn. The trial proceeded against the surgeon on liability and causation only.

1. Disposition. The claim against the hospital was dismissed upon withdrawal. Liability and causation were established against the first defendant in relation to both the consent allegations and the subsequent failure to treat raised intraocular pressure.
2. Under Bolam v Friern Hospital Management Committee [1957] 1 WLR 582, negligence requires proof that the doctor acted outside a practice accepted as proper by a responsible body of skilled practitioners. The test is one of reasonableness, not best practice. Bolitho v City and Hackney Health Authority [1996] 4 All ER 771 confirms that the court must avoid substituting its own assessment for that of reasonable medical opinion.
3. The informed-consent duty under Montgomery v Lanarkshire Health Board [2015] UK SC15 required the defendant to take reasonable care to ensure that the claimant understood material risks, the very limited prospect of achieving the outcome she sought, and reasonable alternatives. The claimant’s particular circumstances made preservation of sight in her better eye especially significant. Merely providing forms and allowing a short period to reconsider the change from left-eye to right-eye surgery was inadequate.
4. The claimant proved that, had she been properly informed, she would not have undergone the surgery. The surgery caused glaucoma in the right eye, and the claimant was therefore entitled to establish liability and causation for the consequences of the operation.
5. Raised intraocular pressure after intraocular surgery required prompt investigation and treatment. The defendant knew of dangerously raised pressure on 6 November 2013, and the appropriate next step was peripheral iridotomy within 48 hours. The claimant was not shown to have been non-compliant with treatment. The five-week delay materially contributed to the damage to her optic nerve and loss of vision.
6. The court concluded on the balance of probabilities that the glaucoma was pupil-block or angle-closure glaucoma. A timely peripheral iridotomy would probably have prevented further damage. The exact amount of damage attributable to the delay did not need to be quantified precisely where the delay materially contributed to the total injury.

First-instance judgment. No appellate history was stated.