Notification of investigation

The HSIB was made aware of a woman who was referred to hospital eye services for urgent assessment of glaucoma. Due to a lack of capacity, there was a delay in the patient’s first appointment and her subsequent appointments over the course of 13 months. By this time her sight had deteriorated to the point where she was registered as severely sight impaired.

After a preliminary investigation with the full cooperation of local care providers, HSIB has decided to launch a full investigation. The focus of this will be the lack of timely monitoring for patients with glaucoma. Specifically, the systemic factors that contribute to the safety risk, the adequacy of the risk controls in place and opportunities to mitigate the risk.

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