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Patient safety in ophthalmology depends on the reliability of diagnostic information that informs clinical decisions. Within independent providers delivering NHS-contracted care, ophthalmic technicians undertake a wide range of physiological and psychophysical assessments, from advanced imagining and functional testing to preoperative measurements that shape condition management and surgical planning. This article explores diagnostics as an often unseen safety checkpoint. It reflects on how structured verification processes, clear escalation pathways and defined accountability within diagnostic teams strengthen system reliability. Viewing diagnostics through a patient safety lens highlights how safe care is sustained through multidisciplinary collaboration and robust system design rather than individual vigilance alone. The NHS increasingly delivers care through a mixed model in which independent providers undertake NHS-funded surgical pathways. This model can increase capacity and reduce waiting times. However, patient safety does not transfer automatically with contracts. It depends on robust systems, clear standards and well-prepared people. In ophthalmology, safety begins long before the surgeon enters the operating theatre. It begins in diagnostics with ophthalmic technicians (predominantly). Preoperative imaging, biometry, visual field testing and other screening inform surgical planning and intraocular lens power selection. National guidance from the Royal College of Ophthalmologists emphasises the importance of accurate biometry and appropriate preoperative assessment in reducing refractive surprise and avoidable harm.[1] When diagnostic governance is strong, risk is mitigated early in the pathway. When it is inconsistent, vulnerabilities may remain undetected. Diagnostic reliability as a safety principle Patient safety literature consistently demonstrates that harm in healthcare often arises not from single catastrophic failures but from accumulations of small system weaknesses.[2] In high volume cataract and glaucoma services, diagnostic processes operate under significant throughput pressure. In that environment, the reliability of measurement systems matters. Examples may include: Failure to recognise poor fixation during biometry. Acceptance of inconsistent keratometry readings without repeat measurement. Inadequate review of visual field reliability indices. Limited escalation of ambiguous imaging findings. Individually these may appear minor. Collectively they influence surgical accuracy and long term outcomes. This is not solely an ophthalmic technician issue. It is a system reliability issue. The role of ophthalmic technicians within the safety system Ophthalmic technicians working in both NHS trusts and independent providers frequently undertake (this is not an exhaustive list): Optical coherence tomography acquisition. Biometry measurement. Visual field testing. Corneal topography. Ultrasonography. Fundus photography. Specular microscopy. Data preparation for clinical decision making. The General Medical Council and NHS England both emphasise that safe delegation requires appropriate training, supervision and clarity of accountability.[3] Where ophthalmic technicians are appropriately trained and supported, structured approaches such as second checker systems, defined escalation thresholds and documented quality standards can strengthen safety by reducing single point failure risk. These systems align with wider patient safety principles embedded within the Patient Safety Incident Response Framework (PSIRF), which emphasises learning, system design and proactive risk reduction rather than individual blame.[4] Independent provider pathways and shared standards Independent providers delivering NHS care are subject to the same Care Quality Commission expectations regarding safety, governance and quality assurance.[5] Patients rightly expect consistent standards regardless of setting. Diagnostic governance in this context should include: Clear standard operating procedures aligned with national guidance. Documented competency frameworks. Regular audit of refractive outcomes and measurement consistency. Structured escalation pathways. Ongoing professional development. These measures support both clinicians and ophthalmic technicians. They strengthen the entire pathway. Capability before expectation Across healthcare there has been expansion of non-medical roles to address workforce pressures. The Health and Social Care Committee has highlighted that role expansion must be matched with training, supervision and system design to protect patient safety.[6] In ophthalmology, ophthalmic technician-led diagnostic services can improve efficiency and access. However, safe expansion depends on: Defined scope of practice. Clear supervision structures. Time for skill consolidation. Access to continuing professional development. Inclusion in governance discussions. When expectation outpaces preparation, risk increases. When preparation is prioritised, safety improves. Prevented harm is rarely visible A repeated scan due to inconsistent signal. A paused surgical listing due to anomalous measurements. An escalated concern about unreliable visual field data. These actions do not generate incident reports because harm was prevented. Safety science reminds us that high-reliability systems pay attention not only to adverse events but to near misses and everyday adjustments that prevent error.[7] Ophthalmic technicians often contribute to this layer of safety. Recognising that contribution is not about professional status. It is about understanding how the pathway functions as a whole. A shared responsibility This is not an argument that ophthalmic technicians alone safeguard patients. Surgeons, optometrists, nurses, managers and other non-clinical staff all contribute to safe care. Rather, it is an invitation to ensure that diagnostic work is fully integrated into patient safety conversations. Questions worth reflecting on include: How is diagnostic quality measured within surgical pathways? Are escalation thresholds clearly defined and psychologically safe to use? Is learning captured from preoperative discrepancies? Are diagnostic staff included in incident learning discussions? In NHS-contracted independent care, as in all healthcare settings, patient safety depends on system design, team functioning and reliable processes. Diagnostics is the first safety checkpoint in ophthalmic surgery. The people delivering it should be visible within the safety framework, not peripheral to it. References 1. The Royal College of Ophthalmologists, UK Ophthalmology Alliance. Quality Standard. Correct IOL implantation in cataract surgery. March 2018. 2. Reason J. Human Error, 1990; Cambridge University Press, Cambridge. 3. General Medical Council: Delegation and referral. Last accessed 2 March 2026. 4. NHS England. Patient Safety Incident Response Framework. Last accessed 2 March 2026. 5. Care Quality Commission. The fundamental standards of care. 23 December 2025. 6. House of Commons Health and Social Care Committee. Workforce burnout and resilience in the NHS and social care. Second Report of Session 2021-22. 8 June 2021. 7. Vanderhaegen F. Erik Hollnagel: Safety-I and Safety-II, the past and future of safety management. Cognition Technology and Work 17(3):461-464.

When Stuart Ball's wife Rachel passed away in August 2025, she was just 47 years old. Her death was not inevitable. It was the result of years of missed opportunities—signs that were there in plain sight but never joined together. What happened to Rachel should never happen to another family. Stuart shares Rachel's story and tells us why he is campaigning for Rachel's Rule—a call for a system safeguard that ensures hereditary risks are not missed. "Rachel’s Rule: Protecting Today, For Tomorrow" From childhood, Rachel faced several health challenges, including asthma, massive urticaria and recurring skin lesions. In 2006, she was diagnosed with her first ovarian cancer. She was still young, and while her gynaecological care was appropriate for the time, there was no referral for genetic assessment. The key moment came in 2012, when a second ovarian cancer and multiple liver hamartomas were discovered—clear indicators of an inherited syndrome. This was the point at which a referral to clinical genetics should have been made and early identification could have changed the course of her care. By 2019, after more than a decade of fragmented treatment, Rachel was diagnosed with breast cancer. Only then was a referral finally made. Cowden Syndrome was confirmed. But by this stage, the damage was already done. Surveillance was started for some organs, but still not for others, including her liver—the very place her cancer would later return. In 2024, she developed advanced breast cancer recurrence with liver metastases. It was treatable, but not curable. Less than a year later, she was gone. A caring, proactive patient failed by a fragmented system Rachel did everything right. She attended every appointment, followed every piece of advice, and even chose preventative surgery to reduce her risk of further cancers. She trusted the system completely. But the system was not joined up. At every stage, she was seen by good people working within a structure that divided her symptoms into separate boxes—each specialist treating their own part, without anyone looking at the whole picture. The NHS has the expertise, the science and the technology to detect hereditary cancer risk early, but without an integrated approach, patients like Rachel fall through the gaps. Her death is not just a personal loss but a case study in systemic fragmentation—how information sits in silos, how guidelines are inconsistently applied and how, without oversight, warning signs can go unnoticed until it’s too late. From personal loss to systemic change In the months following her death, I channelled my grief into something constructive: a campaign called Rachel’s Rule: Protecting Today, For Tomorrow. Its aim is simple—introduce annual hereditary risk reviews for patients with multiple red-flag cancers or associated health issues. These reviews would act as a safety net within the NHS, ensuring that patterns like Rachel’s are recognised early. They would trigger automatic referrals to genetic services when warning signs appear, standardise practice across Trusts and raise public awareness so families know to ask for hereditary risk checks. Around one in ten cancers have a hereditary component. NICE guidelines exist, but application is inconsistent. The NHS Genomic Medicine Service provides world-class infrastructure, but patients can only benefit if they are referred in the first place. Rachel’s Rule would bridge that gap—turning awareness into action and preventing future tragedies. The human story behind the campaign Rachel wasn’t a statistic—she was a wife, sister, daughter and aunt, as well as a much-loved teaching assistant known for her warmth and humour. Even through years of treatment, she never lost her ability to lift others. At her school, Bishop Rawstorne, colleagues remember her laughter and empathy. At home, she made every season brighter: decorating for Christmas, photographing sunsets, planting marigolds in memory of her father. She found beauty in ordinary moments and shared it generously with others. To everyone who knew her, Rachel was the heartbeat of the room. Losing her has left a silence that can’t be filled—but in that silence there is also purpose. Her life now speaks through the campaign that bears her name. Learning from Rachel’s story Patient safety begins with pattern recognition. Just as Martha’s Rule was created to empower families to call for a second opinion, Rachel’s Rule calls for a system safeguard that ensures hereditary risks are not missed. It asks a simple question of our health system: when a patient has multiple serious illnesses or cancers under the age of 50, who is responsible for joining the dots? Rachel’s story exposes what happens when that responsibility is no one’s job. She represents thousands who may be living with undiagnosed hereditary syndromes—people who trust the system, attend every appointment, yet are never given the full picture. Protecting today, for tomorrow The legacy of Rachel’s life is more than memory — it’s momentum. Her campaign is supported by her local MP who continues to raise the issue nationally, and by a number of organisations that have already pledged their support. The Change.org petition is steadily growing, each new signature representing another voice calling for change, another family determined to prevent future harm. Earlier answers save lives. Genetic testing protects families. Structured hereditary risk reviews would turn hindsight into foresight, ensuring that what happened to Rachel will not happen again. You can read more and support the campaign at www.change.org/RachelsRule and download the campaign poster attached below. Rachel's Rule poster.pdf Because the best way to honour her story is to make sure it never needs repeating. Further reading on the hub: From ambition to accountability: why hereditary risk needs ownership now

Katie Dawson is a hypothyroidism sufferer and needs specific treatment to keep herself well. In this opinion piece, she explains why she resorted to sourcing her own medication from abroad. Katie builds on the safety concerns raised in a recent blog by Mary Saunders, and calls for an individualised care approach to hypothyroidism, so that everyone can access the treatment they need.  My less common hypothyroidism When I first started medication for hypothyroidism, I was put on T4, or levothyroxine, which is commonly used in the UK. Unfortunately, it had no discernible effect on my symptoms. Searching for alternatives, with the help of a private doctor, I found a medication from the US that combined two hormones (T4 and T3 and others). I responded well to this treatment. Through genetic testing which I privately sourced, I came to understand that my response was due to faulty genes for the enzymes that convert T4 (storage) to T3 (active). I need T3 in my treatment, as I can’t produce it myself. Barriers to treatment My GP had requested the specific lab tests that I needed (including T3 and antibodies), in order to manage this effectively, but the lab couldn’t accommodate this. T4 and Thyroid-Stimulating Hormone was therefore the only thing I was able to obtain through my GP. There seemed little point in fighting for what they were unable or unwilling to offer. I joined some specialist thyroid self-help groups, digested scientific papers and developed a deeper understanding of hypothyroidism. The costs of the private consultations and obtaining the US treatment were rising to unsustainable levels. I needed to do something different, to manage the financial impact while also getting the treatment I need to feel well. A decision I shouldn’t have to make I got my own blood tests done, researched what they meant for my treatment, and decided to directly source the medicine from overseas pharmacies. I initially continued with the US treatment as advised by the doctor, but it shot up in price and there were a number of quality problems with the cheaper alternative brands. Maintaining energy to function and hold down my job became tricky. This resulted in me switching to synthetic T3 alone, in the hope of having a more consistent product and this is where I have remained . Self-treatment was the only economical way to do it, since despite having an exemption certificate for essential life-saving medicines like these (so they should be free) the cost of T3 in the UK without NHS support was huge. That is not the case abroad, where T4 and T3 are often similar in price and far cheaper. The patient safety concern Many patients like me are sourcing their medicines from abroad in order to continue to have a normal family life and hold down their jobs. There are inherent risks in doing this because they have to take on trust that the sources are legitimate and the products sold authentic, since they can’t vet them personally. They try to find reputable sources from overseas pharmacies but there is always the risk of someone falling prey to a scammer offering unsafe or just ineffective medicines. Self-sourcing absolves the NHS of providing the treatment that individuals need and pushes the risk to patients. They ration T3 due to the cost. There is also a risk the rules that allow the importation of medicine for personal use are revoked. This is a major concern since patients like me can’t rely on the NHS to provide the treatment that they need. We could be left in a far more difficult situation of being untreated and unable to self-source. In fact, many fellow suffers have begged me not to raise this issue for fear that their only way of obtaining effective treatment is removed. Individualised care is overdue There is currently no individualisation of care in hypothyroidism. Unless doctors are prepared to treat the patient in front of them and take account of their symptoms, the treatment of hypothyroidism is ineffective for a significant minority of patients (thought to be 10-20% of over £2m hypothyroid UK patients).[1] [1] Bianco AC. Emerging Therapies in Hypothyroidism. Annu Rev Med. 2024 Jan 29;75:307-319. doi: 10.1146/annurev-med-060622-101007. Epub 2023 Sep 22. Share your experience Have you been affected by any of the issues raised by Katie? Or perhaps you have experienced other medication supply issues as a patient, carer or healthcare professional? Please comment below to share your thoughts with Patient Safety Learning (you'll need to sign up first for free). Further information Thyroid UK - https://thyroiduk.org NHS England: “Hypothyroidism is caused by deficiency of thyroid hormones, which are essential for normal growth, development and metabolism. It can usually be treated effectively with levothyroxine (L-T4) alone. However, a small proportion of patients treated with levothyroxine continue to have symptoms despite adequate biochemical correction. For these patients, oral liothyronine (triiodothyronine; L-T3) may be appropriate.” (source: NHS England » Liothyronine – advice for prescribers) National Institute of Clinical Excellence - NICE guideline NG145 - Thyroid disease: assessment and management

We hear time and time again on the hub about the lack of joined up care and communication within and across organisations. Patients and their families and carers not knowing who to contact to chase up a referral, systems not joined up, lack of communication, having to repeat the patient’s history and medications to every new healthcare professional they see because the notes haven’t been shared or clinicians "don’t have time to read them all". These issues are widespread and urgently need to be addressed if we are to prevent people falling through the gaps and suffering worse health outcomes. In this blog, *Margaret shares her and family's experiences of trying to coordinate their elderly father's upcoming surgery. Interoperability issues My father has dementia and has a complex set of health issues, as a lot of elderly people do. He has a number of comorbidities, including vascular, heart, and cognition and memory problems, that has meant coordinating his care between the care home, his GP, the local hospital and a specialist hospital has been quite complex. There have been multiple issues but there were two that stood out. The first issue was at the diagnostic stage. My father has severe vascular problems and he needed fairly urgent and necessary surgery. In order to assess whether he was suitable for surgery, given his heart condition, he needed a scan. We have had problems in the past in getting access to scans on his heart so the GP said in order to move things on quicker it would be good to get the scan done privately. As the surgery was urgent, we paid to get the scan done at a private diagnostic centre. However, when it came to getting the information from the private diagnostic centre to the tertiary hospital where he was being treated we encountered problems. The hospital couldn’t access the scans from the private hospital because they were two different systems which meant there was an interoperability issue as the two systems ‘didn’t talk to each other’. One of the suggestions I was given was that I could drive to the private diagnostic centre, which was about a 40 mile drive from my house, with a CD, and then they would download the scans onto the CD and I could then drive back to the hospital, which was about another 35 mile drive. There were multiple calls and this was really quite distressing for our family because we knew my father needed access to the scans urgently. In the end they said they’d do another scan in the hospital. Although I don't think there were any kind of safety issues with my father having another scan, it did mean that not only did it cause delays and stress for my father and the family, it was also a cost to the NHS, which could have been avoided. Communication problems between departments Then around the same time, the hospital wanted to do another scan on my father to prepare for the surgery. Again, as it was urgent, I kept ringing the hospital asking if he had his scan yet but because my father was under the vascular and cardiac departments it was often difficult to know who to speak to because one department needed information from the other and they hadn't received it. So I’d get through to one department who then told me to phone another department, or I would be put on hold by someone from admin who didn’t know the answer and would say they’d ring back but didn’t because they were very busy. As a carer/relative you don’t know what’s happening and you become worried that your loved one is lost in the system. I persisted in phoning but, coincidentally, at the same time my sister visited my father’s house to pick up some bits for him. She saw there was a letter from the hospital so she opened it and it was a letter inviting my father in to have an outpatient appointment scan in the hospital he was an inpatient in! I ended up going to PALS. The lady I spoke to was understanding, sympathetic, kind and highly efficient. But she told me this happened all the time as the radiology department doesn't have access to the hospital's IT system, so they wouldn't know my father was an inpatient and would have just invited him in in a timely way but they would have done that as if he was an outpatient. I coordinated between the different departments and we finally got the scan for my father, he had the surgery and survived. However, these delays could have compromised his health because the surgery was urgent and if he had deteriorated whilst waiting that may have killed him. As a family we were very conscious that time was of the essence and we had to push continuously. Lack of information given to families These are just two examples from a multiple of occasions where we as a family were trying to get information. My father was elderly and wouldn’t have questioned the doctor. And because of his cognition issues due to his dementia, and also because he was on high doses of pain medication, he becomes confused and we couldn’t always rely on what he told us. However, often the healthcare professionals wouldn’t tell us things, despite me being next of kin and with documented power of attorney, and told us to speak to my father. So as a carer or relative you are trying to join the dots and work within a health system that isn’t coordinated. What I want to see change On the face of it they may seem like quite small examples, but when they build up, they are significant in terms of risk. My father was a high-risk patient and if it wasn’t for our diligence and persistence he would have fallen through the cracks, to a significant detriment to his health. I didn’t want there to be avoidable harm, an investigation and ‘lessons learned.’ I want us to be working in a coordinated and proactive manner to recognise the risks and void any harm. And for that insight to be used to ensure systems and processes are improved for the benefit of other patients and families. Also, I want opportunities to share my experience, not as a formal complaint but for genuine interest in our family’s customer experience. Again, for learning and future preventative action not for blame. *The names in this blog have been changed to ensure anonymity. Are you a patient, relative or carer frustrated with navigating the healthcare system? Or is your GP practice or Trust doing something innovative to make it easier for patients? We would love to hear your stories. Please add to our community forum (you will need to register with the hub, it's free and easy to sign up) or email us at [email protected]. Related reading The challenges of navigating the healthcare system: David's story The challenges of navigating the healthcare system: Sue's story Navigating the healthcare system as a university student: My personal experience Lost in the system? NHS referrals "I love the NHS, BUT..." Preventing needless harms caused by poor communication in the NHS (DEMOS, November 2023) Robust collaborative practice must become the bedrock of modern healthcare Robbie: A homeless patient’s struggles with the system Digital-only prescription requests: An elderly woman sent round the houses Lost in the system: the need for better admin Digital-only prescription requests: An elderly woman sent round the houses