We have released an interim bulletin relating to the lack of timely monitoring of patients with glaucoma. 

Interim bulletins are released to share further details for each investigation, including how it’s met HSIB criteria, the history of the event it relates to, the national context and any identified safety issues.

National context

The lack of timely monitoring for patients with glaucoma is a nationally recognised patient safety risk, and delays to treatment have been found to cause harm. In 2018 NHS England issued High Impact Interventions for Trusts responsible for Hospital Eye Services and commissioners to help minimise the risk of harm for patients with chronic eye conditions. Other recent national reports have proposed to reduce treatment delays through increasing capacity and managing demand. However, demand for eye services is predicted to rise further with an ageing population and the availability of new treatments to prevent sight loss. This creates an imperative to address capacity challenges in a sustainable way.

Identified safety issues

  • The lack of capacity for follow-up appointments has been an increasing problem over years. Whilst there has been an awareness of the issue, the scale of the problem, and the risk of harm patients were exposed to, has not been fully appreciated by all relevant stakeholders. There has been a lack of forward planning to cope with the increasing demand.

  • Processes and patient administration systems have often not facilitated effective oversight of the issue or supported staff in prioritising scarce appointments to those at greatest risk of loss of vision.

  •  Lack of space in Hospital Eye Services can limit the adoption of different ways of working, hampering opportunities to increase capacity.

  • The national 18 week referral to treatment target, and the requirement to report compliance, has focused attention on first appointments for new patients. There has not been an equivalent focus on follow- up appointments being booked within the requested (clinically indicated) timescale.

  • The financial tariff for follow-up appointments is less than first appointments. This creates an incentive to prioritise first appointments into a service rather than follow-ups. However, for patients with glaucoma, those requiring follow-up are more likely to have a sight threatening condition that needs long-term monitoring and treatment. 


Our investigation will continue to explore the identified safety issues and welcomes further information that may be relevant, regardless of source. 

We’ll report any significant developments as the investigation progresses.

For more information please download the interim bulletin or visit the investigation page