A patient has an eye examination.

Lack of timely monitoring of patients with glaucoma

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month suffer severe or permanent sight loss as a result of the delays.

Reference event

The patient in the reference event is a 34-year old woman who lost sight as a result of delayed follow-up appointments. She saw seven different ophthalmologists, and the time between her initial referral to hospital eye services (HES) and laser eye surgery was 11 months. By this time her sight had deteriorated so badly, she was registered as severely sight impaired.

Investigation summary

Our investigation identified that there is inadequate HES capacity to meet demand for glaucoma services, and that better, smarter ways of working should be implemented to maximise the current capacity.

The investigation makes recommendations for the management and prioritisation of follow-up appointments for glaucoma patients. The findings and conclusions of this investigation are also likely to be applicable to follow-up of patients with other eye conditions, or conditions that fall within other specialties.

The report highlights that there are innovative measures implemented by some NHS trusts that have reduced the risk, but this good practice is yet to be implemented more widely.