A woman has been left with permanently damaged vision after a trainee's "devastating" scalpel slip during delicate cataract surgery.
The unidentified trainee, a consultant and their district health board have been heavily censured following a surgical mishap involving a 71-year-old woman with cataracts.
The senior ophthalmology trainee was being observed by an ophthalmology consultant during a cataract extraction when his scraping tool inadvertently slipped and touched the woman's retina.
"I immediately said 'stop' and took over, but unfortunately the damage was done in that fraction of a second," the consultant told Health and Disability Commissioner Anthony Hill during the health watchdog's investigation into the 2013 incident.
The slip appeared to be a "momentary lapse in concentration" and was like nothing he'd seen in all his years of teaching or practice, the consultant said.
Explaining the error, the trainee said it was "extremely unfortunate that the contact happened close to the centre of vision despite my full concentration".
"I am deeply sorry and will ensure that such accidents never happen."
Mr Hill faulted not only the trainee's error but his failure to properly inform the woman or her GP that he'd made the mistake and that it would permanently damage her eye.
At a follow-up appointment 10 days later the trainee expressed no concern and did not admit to anything being amiss.
It wasn't until a month later, when the consultant saw the woman privately, that she discovered what had happened.
Mr Hill found the trainee's documentation was poor and criticised his failure to inform the woman of the risks involved in having a trainee perform the extremely delicate eye surgery.
The woman, who had been conscious throughout the surgery, told the commissioner the accident had had a "devastating" impact on her life.