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Emergency vitreo- and retinal surgery services have not been arranged in Finland

Unlawful guideline issued by the Helsinki University Central Hospital's eye diseases clinic

1.6.2010

Under an unlawful guideline issued by the Helsinki University Central Hospital's eye diseases clinic, patients suffering from retinal detachment are not operated on during emergency duty periods

Parliamentary Ombudsman Petri Jääskeläinen has given the Helsinki University Central Hospital's eye diseases clinic a reprimand for having issued an unlawful guideline. It is stated in the general guidelines for the clinic that persons whose retina has become detached will not be operated on during emergency duty periods.

The Ombudsman points out that a categorical guideline of this kind is unlawful. No group of patients or category of measures may be excluded from the scope of health services in such a schematic way. It should be clearly expressed in the guidelines that care personnel have a right and a duty to exercise, when necessary and on a case-by-case basis, medically justified discretion. 

The Ombudsman has asked the Helsinki and Uusimaa Hospital District (HUS) to inform him, by 15.9.2010, what measures it has taken to correct the situation.

The Ombudsman has also taken it upon himself on his own initiative to conduct a broader investigation into how adequate health services and immediate treatment can be safeguarded for patients who, as a result of their retina having become detached, are in urgent need of treatment during emergency duty periods.

He has requested a report on the matter from the Ministry of Social Affairs and Health. According to information received by the Ombudsman, emergency-duty vitreo- and retinal surgery services are not currently provided in any hospital in Finland.

"Can a decision that operations will not be performed on an emergency-duty basis, but that instead the patient can lose his or her vision, really be made?"

That is the question a person with a serious retinal disease asked the Ombudsman in a complaint. The person had been diagnosed at the Päijät-Häme Central Hospital as having suffered a retinal detachment, already for the second time, and an operation to correct it had been scheduled for the following week.

However, the symptoms worsened during the weekend. In accordance with established practice, the central hospital's emergency duty service was linked to the Helsinki University Central Hospital's eye diseases clinic and the patient reported there for examination and possibly surgery on an emergency duty basis.

However, a doctor on duty at the eye diseases clinic told the patient that operations to correct detached retinas were not performed during emergency duty periods. The doctor did not examine the patient's eye, but instead relied on the results of examinations performed earlier at the Päijät-Häme Central Hospital.

Without up-to-date information on the state of the patient's retinal detachment, the doctor could not assess whether the eye required urgent surgery. Nor did the doctor consult a backup emergency duty doctor, as could have been done in the event of uncertainty about the need for urgent treatment, but instead sent the patient home to await an operation at the Päijät-Häme Central Hospital the following week.

The patient's right to urgent treatment was not realised

The Ombudsman notes that the patient's right to the constitutionally safeguarded health services and the good-quality health care and medical treatment  provided for in the Patient Act were not implemented in the case of the patient,  whose need for treatment was not assessed individually and on the basis of a clinical examination.

According to the head departmental physician at the Helsinki University Central Hospital's eye diseases clinic, the patient's final vision result could have been better if the operation had been performed there at the weekend rather than, as happened, three days later at the Päijät-Häme Central Hospital. The physician pointed out that it is important to get the retina re-attached before the sharp vision area has come loose.

However, it is difficult to predict in what cases the retina will remain attached, for example with the aid of positioning treatment, until the following weekday. In the complainant's case, according to the head departmental physician, the progress of the detachment had been assessed incorrectly at the eye diseases clinic.

Emergency duty guidelines, general guidelines and practice at eye diseases clinic are mutually contradictory

The Ombudsman does not find it appropriate that the written emergency duty guidelines, the general guidelines and the practice followed in emergency duty at the Helsinki University Central Hospital's eye diseases clinic differ from each other.

The emergency duty guidelines for the eye diseases clinic do not exclude any group of patients or category of measures during emergency duty periods, unlike the general guidelines that have been issued in addition to them. Patients have also been operated on at the eye diseases clinic at weekends if the retina detachment has clearly threatened the sharp vision area and if the backup emergency duty person has happened to be a sufficiently experienced vitreous surgeon.

The Ombudsman points out that sufficiently clear and detailed operational guidelines are essential from the perspective of the protection under the law of both patients and health care personnel. Uniform treatment practices can also be accomplished with them, thereby increasing equality between patients.

Defective entries in patient records

Ombudsman Jääskeläinen considers it a serious shortcoming that entries concerning the patient's treatment in the records kept at the eye diseases clinic were so defective that it was not possible on their basis to make an overall evaluation of the treatment the patient received. Missing from the documents were entries relating to telephone calls, the reasons on which the treatment decision was based and the instructions given to the patient.

Additional info will be provided by Senior Legal Adviser Kaija Tanttinen-Laakkonen, tel. + 358 (0)9 4321.