Criminal trial of optometrist, Honey Rose
The closing speeches from the prosecution and defence have been made in the trial of optometrist Honey Rose at Ipswich Crown Court (13 July).
Setting out the route to a verdict for the jury members, the judge said the jury must, firstly, be sure Ms Rose breached her duty. They then must go on to consider the nature of the breach and must consider whether they are sure in all the circumstances that the conduct of Ms Rose was “something truly so exceptionally bad and in the circumstances gave rise to a serious and obvious risk of death… was in your judgement enough to amount to the very serious crime of manslaughter.”
The judge clarified to the jury that “it may be that you answer no to any questions – in which case you will be led to a verdict of not guilty.”
He said: “Mistakes, even very serious mistakes, and errors of judgment, even very serious errors of judgment, are nowhere near enough to found a charge of gross negligence manslaughter. Even if you have found there is a breach of duty, you still have to go on to consider if it is so bad it amounts to a criminal offence.”
For the prosecution, Johnathan Rees QC spoke to the jury of the inherent implausibility of Ms Rose’s account of events. He challenged the “coincidences” taken together leading up to the defendant being unable to see the optic discs.
He suggested to the jury that these were convenient excuses to explain what she knew was a blatant breach, where the fault is entirely hers.
Mr Rees also suggested “there is a developing theme in [Ms Rose’s] account and it is one of shifting blame away from herself to others who she says didn’t get things sorted… Ms Rose is quick to blame others when accounting for what is her failure.”
Mr Rees told the jury: “Although this is a homicide case, you will readily appreciate that the prosecution do not say that Ms Rose wanted to do any harm to Vincent – “Vinnie” – Barker, nor that she appreciated her actions put him at risk of harm. It is at some stage removed from the usual cases of homicide that come before the courts.”
"Mistakes, even very serious mistakes, and errors of judgement, even very serious errors of judgement, are nowhere near enough to found a charge of gross negligence manslaughter" – judge
For the defence, Ian Stern QC concentrated on the context of other examinations performed by Ms Rose on that day.
He told the jury: “We say that the evidence in this case does not get anywhere near the level where you could be sure. What you have is probability and scorn replacing actual evidence. When you stand back, what is the actual evidence that you have?”
The jury heard that Ms Rose was routinely conducting sight tests “day in, day out” and did so on four other patients that day.
He questioned the reason as to why Ms Rose would have departed from her routine practice with the Barker children, as the prosecution has claimed. The only reason for her to do so, he concluded, was the explanation of photophobia/non-cooperation, as Ms Rose has given.
He said: “In order to not carry it out – to “not bother” which is the only way the prosecution can put it – she would have to be not bothering with Vinnie, and we know that that would be completely out of synch with her routine, day in, day out. There is no evidence that Ms Rose did not try to carry out ophthalmoscopy. In fact, there is clear evidence that she did.”
Mr Stern suggested to the jury that the prosecution did not have evidence to prove the circumstances were not as Ms Rose had described.
He criticised the failure of the investigators to take statements from any of the optical consultants working in the Upper Brook Street practice at the time, even after Ms Rose’s interview in March 2013, and suggested it is unfair for her account to be met simply with “scorn” when the prosecution had not actually called any witnesses to contradict it.
He told the jury: “I venture to suggest that if you were the investigating officer, if you had not done so before, you would have gone directly to that store and asked what is the position in relation to each of the optical consultants. You would have taken a statement from each of the optical consultants working on that day, you would understand how the machinery was working, and you would understand whether they had shown an image to anybody on that day. They may not remember, but they may, given that it was a relatively short period of time.
“I am not asking you to speculate about what they may have said. The important point is that you are being asked to conclude that this did not happen on the basis of no evidence. On the basis that not one of the optical consultants who was working on that day has made a statement. That is – if I may say – somewhat incredible.”
Summing up, Mr Stern said: “This case is a tragedy, but it will not be made any better by the conviction of somebody wrongly on the evidence you have heard.”
The jury is out for a verdict on the case.
Criminal trial of optometrist, Honey Rose, continuesThe morning session (12 July) in the trial of optometrist Honey Rose saw the defendant give further evidence to the jury.
Under cross examination from prosecution counsel, Johnathan Rees QC asked questions about the difference between the cup-to-disc (c/d) ratio recorded for Amber Barker, sister of Vincent – “Vinnie” – Barker, and what appears in the images.
The jury heard the prosecution suggest to Ms Rose that she did not, in fact, conduct direct ophthalmoscopy of the back of Amber Barker’s eyes. Ms Rose said that she did.
The prosecution also suggested to Ms Rose that she should have double-checked the c/d ratio when finding it had gone up from 0.2 two years before.
Agreeing that the c/d was getting bigger, Ms Rose said: “But it is not more than 0.3 so it is within the range…There would have been cause for concern if it had been more than 0.3, but it wasn’t.”
The prosecution put it to Ms Rose that she had not recorded answers to all of the questions about symptoms, such as flashes and floaters, for Vinnie, and suggested that indicated she had not asked.
Ms Rose told the jury: “Every optometrist has to ask questions about floaters etc, but it’s not necessary to record everything. If you go back to Vinnie’s records from 2010 to 2011, you don’t see it there.”
She added: “You have to record if there is an issue but not if it is normal. You don’t have to record. It is the optometrist’s discretion.”
The jury heard Mr Rees ask the defendant a series of questions about the tests prior to the ophthalmoscopy of the optical disc, which involved light and fixation.
Ms Rose described the nature and extent of Vinnie’s photophobia and poor fixation when she tried to look at the optic disc. She told the court: “I was doing [the examination] and noticed that he was not looking straight ahead… He was getting distracted… closing his eyelids.”
Asked by the prosecution if she “could remember this sort of detail,” Ms Rose said: “Yes.”
Ms Rose was challenged by the prosecution on the fact she did not say anything to Vinnie or his mother about the problems that were apparently preventing her carrying out the examination due to photophobia.
Challenging Ms Rose’s assertion that she may have asked Vinnie “is this light hurting you,’ Mr Rees said: “I suggest you didn’t, because if you had, Ms Barker would have heard.”
Ms Rose replied: “If [Vinnie] had severe photophobia I wouldn’t have been able to do the tests, and the mother would have said. She said he didn’t have any issues.”
The jury heard that Ms Rose attempted to carry out direct ophthalmoscopy on the back of the eye for “a few minutes” before turning to the fundus image.
Asked by the prosecution if, “in this time, were Vinnie’s eyes closed the whole time?” Ms Rose replied: “No. It was poor fixation.” She confirmed that she “didn’t get a view of the optic disc…If I had I would have written it down straight away, but I didn’t.”
Mr Rees said: “Anyone looking at [the record] would think you had conducted direct ophthalmoscopy, and that is why I say it is misleading.” Ms Rose denied that recording the periphery as “normal” without any note that she had not actually seen it was potentially misleading.
Turning to the interview in March 2013, the prosecution asked Ms Rose why she gave the police the answer that she thought she could tell the periphery from photos shown to her.
Ms Rose told the court: “I was nervous at that time. It was my mistake. But I did say in interview that it only shows the central retina. I told them that I made the assumption form the photos, but I didn’t tell them I looked at the periphery in the photographs.”
Asked by the prosecution about Ms Rose’s statement to the police which said “sometimes” testing times are “shorter for kids because they assume with kids it is not going to be problems,” Mr Rees said: “You aren’t suggesting that the company’s policy about how much time there is would affect the competence of your sight test?”
Ms Rose said: “No. But I have to finish on time.”
Mr Rees asked: “You indicate that there might have been an assumption on the part of a company that a kid would be fine. You wouldn’t make that assumption would you?”
Ms Rose told the court: “I didn’t mean assumption. [Boots Opticians] gives the appointment times… But I did a full test on them, and I did the two additional tests with Amber... I did the normal tests on both of them, I didn’t miss anything.”
Asked by the prosecution if Ms Rose would agree that a “series of unfortunate circumstances” prevented her seeing the pathology, she said: “Yes.”
During the morning and afternoon sessions, the court heard testimony from Professor Bruce Evans.
Professor Evans told the jury that under some circumstances it could be reasonable for the optometrist to determine not to go on with the direct ophthalmoscopy if they have already looked at a retinal image.
He said: “There is a point when you realise you are not getting their cooperation, you are starting to lose their attention, and the optometrist has to say what am I going to do? I can accept that if there is a good quality photograph of the central retinal area and if they judge that they are not going to be able to get a view of the back of the eye, then they may choose to rely on the photograph.”
"I am a very cautious practitioner because of the expert witness work I do, but I don't always keep the record in the same way. Also, with a child the optometrist is trying to keep the child's attention – a good optometrist should be concerned with having accurate records but it's not the only thing" – Professor Bruce Evans, expert witness
The jury heard Professor Evans support the fact that Ms Rose did not record the answers to all the “symptoms” questions in Vinnie and Amber’s eye examinations, saying it was unfair to criticise a practitioner for this.
Professor Evans stated that, in some situations, one would not involve the parents, and would not comment on the difficulty in order not to make a fuss – and focused on the optometrist in the moment doing the best they can with the situation and making judgment calls.
He told the court: “With children, they might be distracted and intend to look where the optometrist is asking [them to], but a thought comes into [the child’s] head. The optometrist may record it, or they may just make a mental note in their head that they are not getting the result they wanted.”
Professor Evans challenged the focus on c/d ratios. He explained: “We’ve been talking about c/d ratio a lot, but it is a measure which is almost artificial in someone under the age of 40.
“Like most medicine there are exceptions and you can get glaucoma in children. It is a case that it would occur about two in 100,000. Most cases of juvenile glaucoma, however, are secondary – that is, it develops secondary to other eye problems that a child has. Most of those an optometrist won’t see because those children will be under the case of the hospital. The best estimates of primary glaucoma are that you would see approximately one in case in 300,000,” he added.
“I have seen about 30,000 children in my career and have never seen juvenile glaucoma. It is right to say I would hate to miss it, but the odds of me ever seeing it are very, very small.”
Professor Evans also told the court: “In my own practice, I take pictures of each person’s eye myself – I am quite old fashioned like that – and I use a 3D scanner, which is the next generation, as it gives a computer calculated c/d ratio. However, I will still write down what I estimate the c/d ratio to be looking inside the eye with the ophthalmoscope. What is written in my paper records and computer records is what I saw with my eye. There is no point putting down what you got in the photograph or computer because you’ve got that photograph. And if the photographs were lost, the next optometrist would be able to look in the eye with an ophthalmoscope and they would be comparing like with like.”
Under cross examination from the prosecution, Professor Evans for his opinion on Ms Rose’s statement that it was “discretionary as to whether she recorded the answers to questions regarding floaters and so on.”
He told the court: “I thought it was a little unfair for a practitioner to be criticised about not making their records in exactly the same way. There is variation in the way she recorded answers to motility, where she has done a very good job. I am a very cautious practitioner because of the expert witness work I do, but I don’t always keep the record in the same way. Also, with a child the optometrist is trying to keep the child’s attention – a good optometrist should be concerned with having accurate records but it’s not the only thing.”
The prosecution asked Professor Evans for his view on the discussion in the case about photophobia or poor fixation.
He told the jury: “I doubt very much that the optometrist in that situation is having an analytical discourse in their head. The optometrist in that situation is thinking – and I have been in that situation – ‘I am not seeing what I need to see.’ And I am sure in the months that have gone by…I am thinking what is in my head in those situations, and it is just “I am not getting a good view.” If you are constantly badgering the child, actually that can make the situation worse. I am not saying there is a black and white answer to this, but it is for the optometrist on the day to judge what is best. If they think they are not going to get the best result by complaining to the child, or the parent, then they rely on other methods.”
The jury heard Professor Evans conclude that when a c/d estimate differs from 0.1 in an image to 0.5 with ophthalmoscopy (as the defendant said it did in her examination of Amber) he would have double-checked the ophthalmoscopy. If it had gone up from 0.2 to 0.5 over two years, he would have checked again and possibly run further tests.
Professor Evans also told the jury that, had he been unable to view the back of the eye despite trying for a few minutes, he would have noted this on the record. In the situation where he could not observe the back of the eye through ophthalmoscopy, and so had not seen the periphery at all, he said that he would have told the parent this, and would expect a competent ophthalmologist to recall the patient within six months at a maximum.
Professor Evans agreed that if an optometrist failed without good reason to look at the back of the eye, they have breached their duty and fall “far below” the standard of a competent optometrist.
The case continues. The trial is expected to end this week.
Day six in the criminal trial of optometrist, Honey Rose
The afternoon session (11 July) in the trial of Honey Rose saw the defendant give evidence to the jury.
Under questioning from her defence council, Ian Stern QC, Ms Rose was asked in detail about the sight tests she conducts on patients and the methodology she uses.
Ms Rose told the jury: “When a patient comes into the practice, I would first be made aware of the patient. I would check whether there is a board ready in the pigeonhole outside the consulting room. I will check the records and see if it is a new patient or an existing patient. I will check the record to see if there is any pathology, or contact lenses, or anything I need to be aware of. I will check if a fundus photograph has been taken, and whether there is anything I need to be concerned about.”
The jury heard from Ms Rose that she looked at the retinal images for Vincent – “Vinnie” – Barker, and Amber Barker, his sister, before the start of the appointment.
She said: “On 15 February 2012, I have a little bit of a recollection of working at Boots in Ipswich. When I was trying to access the photograph on my system in the consulting room, I couldn’t actually access the fundus photograph on my system, and I informed colleagues. I was there on 14 February as well, and there was a similar issue too. When I was interviewed in March 2013, I mentioned this to the police.”
The jury heard Ms Rose confirm that, if she had seen the 2012 images of Vinnie’s eyes, she would have referred him to hospital immediately.
She said: “I had looked at the digital images before calling [the Barker family] in. I had done it by going to the pre-screen room. I had asked one of the colleagues there to bring the picture up. I looked for the pictures for Vinnie and Amber. The images were put on the screen by a colleague – an optical consultant. I don’t remember who that might have been.”
She added: “When I saw those images before I saw the family, I did not notice that there was any difficulty or pathology. The photos that were shown to me looked normal – there wasn’t any kind of pathology at all. Depending on the pathology, I would have referred them either urgently or emergency. I would have written a referral letter. In this case, I don’t remember whether I used the slit lamp or not.”
In a question from the judge to establish if the defendant “is speaking from memory or from reconstruction – because the jury will be very interested” – Ms Rose clarified that she “could slightly remember” what she did, as the examination took place in February 2012 and she was made aware of the problem in September. Ms Rose also told the jury: “I saw 18 patients or so that day.”
Ms Rose told the jury that she “did conduct ophthalmoscopy on the inside of Amber’s eyes” She said: “I checked with an ophthalmoscope the lids, lashes etc. up to the lens, at 10cm from the patient. From the disc onwards I was standing at 2cm from the patient and I noticed that the disc was 0.5. That is from ophthalmoscopy.”
Ms Rose also told the jury that she had problems carrying out the eye examination on Vinnie.
She said: “Vinnie was showing slight photophobia and he was getting distracted and not looking where I was asking him to look… I mean he was closing his eyes. I was thinking it could be photophobia. Also he wasn’t looking where I was asking him to look. I didn’t know if it was because I was coming more close to him, so I tried to reduce the light but it didn’t get any better.”
The jury heard the defendant state that she wrote down that the periphery was “normal” based on the fact that Vinnie had not reported any issues with his sight or eye health, which she now accepts was not correct.
She explained: “On the retinal photograph I was able to see from the disc to the macula. It says 0.5 cup-to-disc (c/d). The retinal ring is shallow, pink, healthy, distinct… [The] macula was clear. The periphery I have written [as] normal because the patient didn’t any issues.
“You cannot see the periphery on the digital image. I have written normal because when I went through the symptoms he had, he didn’t have any floaters, flashing lights, sudden loss of vision. He didn’t have any issues, which indicates that it is normal, so I wrote normal.”
“I do not think that was a good thing to do now,” she added.
"I did not see that image on 15 February 2012. I would have referred him straight to the hospital. This is not difficult for me to see, I can see it easily" – Honey Rose
Ms Rose was presented a retinal image of the left eye of Vincent Barker from 2012 as part of the evidence bundle. She said: “[It] is not the image that I saw on 15 February 2012. That is because, if I did see the image on 15 February, I would have referred him straight away to the hospital because the disc is not clear at all – the point where the vessels start from, the surrounding circular area, there is no demarcation. The optical disc is completely swollen and blurry in this case, and the vessels are all distorted. And there is no cup-to-disc ratio either. That could never be described by me as 0.5.”
She added: “[In the] right eye, the optic disc is completely swollen, there is no cup-to-disc ratio, the vessels are completely distended etc. I did not see that image on 15 February 2012. I would have referred him straight to the hospital. This is not difficult for me to see, I can see it easily.”
The jury heard the Ms Rose had not noted down Vinnie’s photophobia on the record because “it was only slight.” She said: “If it had been severe I would have done, to warn the next optometrist. But because it was slight, I didn’t.”
The jury heard that Ms Rose conducted additional, supplementary tests on all three of the Barkers as part of the eye examination. This included ‘a colour testing book’ test on Amber.
Ms Rose could not remember who the optical consultants working on that day were, but said she had reported computer problems to them on that day and the previous day.
Under cross examination from prosecution counsel, Johnathan Rees QC challenged the accuracy of Ms Rose’s recollection of the events on 15 February 2012.
The jury heard Ms Rose confirm that she could recall that there was nothing unusual about the Barkers’ appointment. She also could remember when and where she viewed the retinal images, the reason she had to stop direct ophthalmoscopy for Vinnie, and the fact that she carried out direct ophthalmoscopy for Amber.
However, the defendant confirmed that she could not remember who she spoke to at the Boots Opticians Upper Brook Street practice about the computer problems she was having, or how the images were displayed on the screen.
Asked by Mr Rees if Ms Rose could remember anything about Vinnie’s examination that day, Ms Rose said: “As I told you, I worked there on 14 and 15 February, and it was the only two days that I had a problem with the computer. And there was only one patient that I relied on to use the fundus photograph to make a judgement… I don’t remember if it was Vinnie or not, but I remember there was one patient I relied on the fundus photograph alone.”
Asked if, in every case where a fundus photograph had been taken, she checked it either during or before the examination, Ms Rose added: “Yes. But I know there was a patient where I relied on only the fundus photograph, I knew there was one.”
Discussing Amber Barker’s examination, Ms Rose told the jury: “I didn’t rely on the fundus photograph for her, I relied on the ophthalmoscopy.”
Mr Rees asked Ms Rose: “You would have made a note, in case you needed to rely on it. And in respect of Amber you would have put something like 0.1?”
Ms Rose said: “Yes. But always in respect of the photograph and the direct ophthalmoscopy it is different.”
Mr Rees said: “But in respect of some of the patients which are by direct ophthalmoscopy you have said, you got them right.”
Ms Rose responded: “Not right, it says reasonably right. But when I am looking at the patient’s eye directly, I rely on that… The retinal photograph…is a better way, but I am looking at the eye directly so why should I rely on the photograph?”
Mr Rees said: “This is not a small difference, this is a big difference. When you got such a different result, did you think it would be sensible to double check?”
Ms Rose said: “How would I know if I double checked or not? But I would have double checked.”
Asked if she was sure she looked at Amber’s retinal photographs, Ms Rose said: “Yes.”
The jury heard the prosecution suggest to Ms Rose that she relied too heavily on the optical consultants to point out problems for her.
Highlighting an extract from Ms Rose’s earlier statement, where she said “if there is any problem, the optical consultant writes it on the record. Mainly they will write it on the record,” he asked Ms Rose if she was suggesting that it is the optical consultant’s responsibility to check the images for her.
Ms Rose denied this, saying: “No, I didn’t mean that. I meant normally there will be something on the record, but I didn’t mean it is their responsibility, that is for me."
She added that she did not rely heavily on the ‘optical consultant,’ telling the jury that it was the case that if there is nothing on the record, she would not “just take their word for it.”
In relation to the retinal images on the screen or the capture screen, Ms Rose confirmed that the patient name is always attached. Asked by Mr Rees if it would have been very easy to spot if someone has brought up the wrong one, Ms Rose said: “I didn’t check the name… On those two days I didn’t check the name.”
Ms Rose added that it would have been a “good idea” to check, “but on those two days I didn’t check.”
Asked by Mr Rees if Ms Rose was suggesting to the court “the optical consultant got the wrong patient. Not the wrong year, but the wrong patient,” she said: “I think so but I can’t say for sure.”
The case continues. The trial is expected to end this week.
Day five in the criminal trial of optometrist, Honey Rose
The morning session in the trial of Honey Rose dealt with a statement (dated 18 May 2016) from Rodney Fisher, who worked at the Boots Opticians Upper Brook Street practice as a contact lens optician.
In his statement the jury heard his recollection of any IT or technical problems with the fundus camera in the practice at the time.
He said: “I cannot recall any specific problems from the time of the incident. With regard to general IT, there have been times when the system has been unstable and we experience a loss of use. A call is made to IT and we regain use within an hour. Usually these issues occur first thing in the morning rather than during the day.”
Asked about the fundus camera, Mr Fisher’s statement read: “I can recall it not working. I do not use it personally within my role. I am aware of it not working because it is an unusual problem and people within the store will try to fix it first before calling IT. When called, IT will fix it usually within an hour.”
He added: “I use the contact lens room which is just off the pre-screen area, so I am aware if there are issues with the camera. It is difficult to estimate how often these problems happen over such a period of time. I can say these problems are only occasional.”
The morning session closed with agreement between the prosecution and the defence on a range of facts relating to the case, known as the ‘admissions.’
This included personal information in respect of Vincent – “Vinnie” – Barker, Amber Barker and Ms Rose. The jury heard Ms Rose has no convictions, cautions, findings or reprimands. She has no adverse findings recorded against her by the General Optical Council.
The process by which the defendant qualified as an optometrist in this country and the relevant statutory duty of care owed by an optometrist was agreed, the jury heard.
The jury was also told that it is agreed Vinnie’s death was preventable right up until the day of his death.
Consultant ophthalmologist on the case, Dr Kostakkis, noted that the retinal images of Vinnie that were taken in 2011 seemed normal and did not raise any cause for immediate concern.
However, he said the 2012 images were “remarkably different and show acute congestion of the veins and swelling of the optic nerve. They would cause concern and the need for immediate intervention and referral to hospital.”
"I cannot recall any specific problems from the time of the incident. With regard to general IT, there have been times when the system has been unstable and we experience a loss of use" – Rodney Fisher
He added: “The sad fact is that Vinnie’s death could have been prevented if this defendant had done her job properly, and that she simply failed to do. Her conduct was so far below the standard of that expected, the standard that members of the public – you, me, Vinnie’s family – are entitled to expect, that it does amount to a criminal offence.”
Dr Kostakkis noted Vinnie’s case was very unusual because he displayed very few symptoms. He said he would expect a patient with hydrocephalus to display constant headaches and severe vomiting, which was not the case with Vinnie.
A consultant neurologist, Ms Fernandes, at Addenbrooke’s Hospital, Cambridge University Hospital, stated in a report that hydrocephalus is a treatable condition, but one that requires surgical intervention. She noted this would have been the treatment of choice for Vinnie.
It was Ms Fernandes’ opinion, the jury heard, that up until Vinnie’s acute deterioration and death, his condition was treatable, and that there is no reason to believe that treatment would not have been successful.
Consultant ophthalmologist Susmito Bizwaz said that photophobia could have been caused by the brain condition Vinnie was suffering from at the time.
Details from the staff in the Upper Brook Street practice were also agreed on as part of the admissions. These included the dimensions of the examination room, and recorded facts relating to problems with the IT systems.
It was agreed that, apart from the calls on 11 October 2011 [and one other] – in respect of which there are no records available – and a visit on 12 October 2011, the jury heard that no other calls related to problems with the retinal camera.
In relation to the exhibits and the defendant’s interview, the jury heard that the copies of the retinal images Ms Rose was shown in her interview did not have the patient’s name, reference number or date on them.
The prosecution has concluded its case.
The case continues. The trial is expected to end this week.
Day four in the criminal trial of optometrist, Honey Rose
The morning session in the trial of Honey Rose opened with the agreed summary of Ms Rose’s second interview with the police.
The jury heard that Ms Rose was asked about the retinal images of Vincent – “Vinnie” – Barker.
She told the attending officer, DC Parsonson, that she was not trained to use the equipment, and that she did not take the retinal images.
Ms Rose was shown the images taken in 2012. She agreed that the pathology was obvious even to an unqualified person, but that she had never seen the pictures before.
Asked how she viewed the images, she said: “On the main screen. Because I don’t know how to use the screen. Not inside the testing room because it wasn’t working.”
She added that in the room where she carried out the eye examination, the screen wasn’t working. “There was no connection. And even though I had told the staff – two of the staff there – they didn’t pay any attention,” she said.
The jury heard from Ms Rose’s statement that she believed that there was no requirement for her to be trained to use the camera. She said: “I don’t have to be trained because I work everywhere, so they don’t have the responsibility.”
Ms Rose added that optical consultants (also known as optical assistants) are trained, and have a responsibility in the first instance to identify concerns to the optometrist.
She said: “If they find anything suspicious, it has to be [brought] to the optometrist’s attention, unless they might not have checked it. But usually they should write on the record for the optician’s attention.”
“From the 2012 fundus photography… even an unqualified person would know, totally the eye has gone – the way the vessels are all wavy…Because usually they take these photographs a couple of times a day. Because they do it every day in the practice as a routine, they know what a normal eye looks like.”
The jury heard that because Ms Rose did not know how to use the equipment, she would not have known how to check who the patient was either.
She said: “It is usually done by colleagues, so if I ask for help; it is them who has to double-check the name and date of birth, because I don’t know. [The name] doesn’t come up. It might show the name, but I wouldn’t know.”
Asked by DC Parsonson if it was possible that Ms Rose saw someone else’s images, she said: “Well I couldn’t say, because someone else was showing them.”
Ms Rose added she was “totally reliant” on other members of staff to show her the correct image.
Ms Rose said in her statement that if she had seen the correct images for Vinnie, “I would have referred them by emergency referral. I would write a letter or call the hospital and say I have seen a papilledema for Master Vincent. It could be caused by intracranial pressures, brain pressures, so I would write a letter and make an emergency referral to that hospital.”
Asked about her training for papilledema, Ms Rose said: “We already know about this and what to do if the patient presents with papilledema.”
"The competent optometrist is not entitled to delegate the responsibility for examining the retinal photograph to the optical consultant" – Richard Booth, optometrist
In the morning and afternoon sessions, Richard Booth, an optometrist partner in a practice and chairman of NHS Merseyside Eye Health Network, was called by the prosecution as an expert witness.
The jury heard Mr Booth set out the minimum competencies and standards expected from a reasonable optometrist in terms of testing and referrals.
He explained the duty to conduct “internal” examinations cannot be delegated and nor can that act of viewing the fundus photograph to an optical consultant.
The jury also heard Mr Booth challenge Ms Rose’s assessment of the record.
Mr Booth said: “The record [by Ms Rose] does not support what is in the retinal photograph. The retinal photograph only deals with the central 45o. It only deals with the cup-to-disc (c/d) ratio and the macula. It doesn’t deal with the periphery. So the discrepancy is on those two main things: the c/d ratio; and the description of the optic disc.”
He added: “Having looked at the photographs, my assessment of the c/d ratio is that it is virtually non-existent. The description of the optic disc being “shallow, healthy, rim indistinct” differs because there isn’t a cup so it can’t be shallow, it certainly isn’t healthy and the rim is very distinct. So on all three, it is incorrect.”
Mr Booth told the jury: “The optometrist cannot delegate the internal examination. You are making a clinical judgment. As far as you use retinal photographs as part of your examination, you can delegate the taking of the photographs. But the viewing of them, that is a clinical judgement which only you are qualified to make. The core competencies include the ability to detect abnormalities and create a management plan responding to what abnormalities you may see.”
He added: “The use of an ophthalmoscope is also a core competency. You start that in the first year of university. In a typical day, the optometrist would use an ophthalmoscope every time they look at the back of the eye. Unless doing contact lenses, every time [they] see a patient, if [they] see 20 patients then 40 times a day.”
In relation to the treatment of Vinnie, Mr Booth told the jury: “Whether you used the ophthalmoscope, the slit lamp or the photographs, I would expect a competent optometrist to have seen the swollen discs. There is no question of a competent optometrist focusing on the optic disc by whatever means and not seeing those signs. Not with those images."
He added: “If there was no good reason for not conducting an internal exam with an ophthalmoscope or slit lamp, and an optometrist failed to do so, it would be a fairly massive breach of duty of care. If there was good reason for not being able to do it with an ophthalmoscope or a slit lens and you had the opportunity to refer to retinal image and you failed to for no good reason, then that would be a fairly massive breach of duty of care.”
The jury heard Mr Booth explain that there is no sign of photophobia in the record of Vinnie’s 2010 or 2011 eye examinations. Mr Booth said he could not answer whether the papilledema present in 2012 could have caused an onset of photophobia.
Mr Booth also said that if Vinnie was showing signs of photophobia in 2012, and if it was so significant as to have prevented any test being carried out, he would expect a competent optometrist to have noted it on the patient record.
The jury heard that if a child is “flinching” due to photophobia, Mr Booth would still expect the optometrist to try and complete the examination. He noted that going from the external to the internal exam takes a matter of seconds, and the internal exam always starts on the optic nerve, which is the least sensitive to light. Also the instrument light beam can be turned down.
Mr Booth reiterated to the jury that an optometrist has a duty to review the fundus photographs themselves, regardless of what an optical consultant has or has not said.
He said: “The competent optometrist is not entitled to delegate the responsibility for examining the retinal photograph to the optical consultant. If there are retinal photographs available, regardless of what is or is not noted on the record, it is the duty of the competent optometrist to check those photographs. You cannot rely on somebody who has not got the qualification to make any sort of decision.”
Under cross examination from Ian Stern QC, the jury heard that Mr Booth agreed that in some circumstances a reasonably competent optometrist can carry out an assessment of the internal eye from a single fundus image.
He said this was only in “very exceptional circumstances,” including behavioural difficulties such as dementia or violent behaviour. If doing so, the optometrist should recall the patient within a maximum of six months.
The jury heard that a patient displaying photophobia in the eye examination could have shown no signs of it in normal life. They also heard that poor fixation can be unknowing by the patient and particularly so in children.
Mr Booth told the court that, when encountering problems with poor fixation or photophobia with a child, it is particularly important not to do anything to upset them or put them off. He said that dealing with such issues is a question of subjective judgement and the individual optometrist doing the best they can.
Mr Booth said that that it is never acceptable to “assume” the periphery is clear because there are no other symptoms or abnormalities in any other areas. In cross examination, Ian Stern stated that Ms Rose accepts this because she did not assume – she said she checked it from the photograph.
In re-examination Mr Booth clarified his viewing, repeating to the jury that the periphery could not be seen in the retinal image in question.
However, Mr Booth accepted that the assessment of c/d ratio is subjective and there can be variations between practitioners.
The defence team referred Mr Booth to the Harper study, as part of the evidence bundle.
The jury heard that Mr Booth accepted that this study showed significant variation in c/d assessments between practitioners.
Mr Booth said: “The work would have been done in 1997–98 when photography was much different to what it is now. I think it is an interesting paper and should perhaps be revisited, but I don’t think we can draw conclusions as to what goes on in practice nowadays.”
He said that the sample size was very small (five), the quality of retinal photography has improved dramatically since the late 1990s, and comparing film photographs and digital photographs is like “chalk and cheese.”
Mr Booth stated that Ms Rose should have investigated a c/d ratio of 0.5 in Vinnie, when it had gone up from 0.2 and 0.3.
He stated that her c/d assessments on four other patients that day were all reasonably accurate and indicated an ophthalmoscope was used, but her assessment of Vinnie’s sister, Amber Barker’s, c/d ratio was not within the margin of error.
The case continues. The trial is expected to complete in two weeks.
Day three in the criminal trial of optometrist, Honey Rose
Witnesses for the defence have been giving evidence in day three of the trial of optometrist Honey Rose, who faces the charge of gross negligence manslaughter following the death of an eight-year-old boy.
In the morning session the jury heard from Carol Cocker, an ‘optical consultant’ who worked in the Upper Brook Street Boots Opticians practice in Ipswich, and has since retired from optical practice.
Ms Cocker described her role to the court, including capturing a retinal image, and the handover to the optometrist. She explained: “I don’t have any formal training about identifying features on the images.”
She added: “If I had taken an image that I thought looked abnormal – even though we weren’t allowed to talk to the patient about it – I would tell the optometrist that it didn’t quite look right to me, just to pre-warn them, for example if there was a shadow on the retina.”
“If the optometrist wished to view the retinal images, they would just have to put in the reference number or the name and it would come up on their screen in their room, so they could look at it while they were doing the test,” Ms Cocker explained.
"I do recall problems with the system during the time I was working there. I can remember that we wouldn't be able to take an image" – Carol Cocker, optical consultant
He continued: “It is the prosecution’s case that the failure to detect the swelling and refer him was grossly negligent on her part. It fell so far below the standard to be expected that it was criminal in nature. Of course we can all make mistakes and errors of judgment in our professional lives. They can even involve the breach of a duty of care we owe to another. None of us are perfect. We are not talking about a mistake which merits a ticking off from the boss or even sanction from the regulatory body. We are talking about something so bad that it amounts to a criminal offence.”
He added: “The sad fact is that Vinnie’s death could have been prevented if this defendant had done her job properly, and that she simply failed to do. Her conduct was so far below the standard of that expected, the standard that members of the public – you, me, Vinnie’s family – are entitled to expect, that it does amount to a criminal offence.”
Asked by the prosecution if she remembered seeing Vincent – Vinnie – Barker, Ms Cocker said: “I don’t have any recollection of that patient… I can’t remember if it was me that took the retina images that day. It could have been me, but on some days there were two people working on the pod if it was busy.”
The jury heard from Ms Cocker that problems with the optical equipment did occur, including with the fundus camera. She said: “I do recall problems with the system during the time I was working there. I can remember we wouldn’t be able to take an image. When you pressed the shutter it just wouldn’t work, so we had to report it and get it fixed. The external video monitor would be blank, [and] you wouldn’t be able to take an image. I didn’t fill in a log or report, I would just tell the manager.”
In evidence to the jury, Denise Saunders, a dispensing optician and practice manager at Upper Brook Street practice, described the remit of her role at the time.
On questioning from the prosecution, Ms Saunders explained the timetabling of patients’ appointments, including 15 minutes with the optical consultant, and 25 minutes with the optometrist. Asked if there was flexibility in the process, Ms Saunders said: “Yes, there would be flexibility, as long as all the tests are carried out.”
The jury heard that Ms Saunders could not recall the computer system or the camera at any point failing to her knowledge. “As practice manager, someone might bypass me and deal with it another way. The practice was to phone our IT service and let them know of any faults, and that wouldn’t necessarily have come to me.”
She added: “If any optometrist had a problem with the equipment, they would let one of their colleagues know this was potentially the people planned for the day to carry out the admin tasks, on shop floor level. So they would let them know straight away. If it was one of my employed consultants, they would delegate one of the optical consultants to ring IT. A locum [optometrist] would have done the same, [and] asked the first person they could find.”
The jury also heard from Peter Birch, the present practice manager at the Upper Bridge Street practice.
Mr Birch said that he did not have any qualifications relating to eye care. He added that he has been involved in obtaining and providing information for Boots’ legal department for passing on to the investigating bodies.
Under cross examination, Ian Stern QC, the defence counsel, asked questions about a disc provided to the police, relating to photos that were taken of patients by Ms Rose on the day in question.
Mr Birch said: “I didn’t produce [the disc] myself. It was produced by head office and delivered to my store to be handed to police.”
Discussing this evidence, the defence counsel said that the disc supplied to the police stated that it was the patient number of Joanne Barker. However, the jury heard from the defence that this was incorrect information, and the patient number was not Ms Barkers’.
Addressing Mr Birch, Mr Stern said: “I’m not criticising it, but you read the statement, signed it, and read the declaration, and I’m not criticising you, but despite that it is easy to miss something in the statement, as you did?” Mr Birch agreed this was the case.
In the final morning session and the afternoon session, the jury heard from Martin Donoghue, currently technology innovations manager for Boots Opticians.
The jurors were told how the branch’s computer system works, and how it records data.
The jury heard that on the day in question, the computer system had logged a call at 10.55am to say that there was a power surge. A call a minute later was about a power cut.
Mr Rees for the prosecution asked Mr Donoghue if the consulting room computers were connected by cables to the fundus camera. Mr Donoghue said: “From the information I have, I can only say from what’s in the log, the only system that was affected was the practice management system – in the centre of the diagram. That is independent from the retinal camera system.”
Mr Donoghue added that: “According to the log, no calls were made relating to the retinal camera system. The images taken of Vinnie’s eyes were at 10.04am or thereabouts and his sister’s at 10.10am.”
Under cross examination from the defence, it was put to the witness that there was a high number of IT problems reported to the help desk, and the help desk’s record of problems relies on the accuracy of the staff reporting them.
Mr Stern said: “It’s clear isn’t it, that the information that is on this log is only as accurate as the speaker who has provided the information. Because one person is describing it as a power surge and another as a power cut, which is on the face of it incompatible?” Mr Donoghue agreed.
Asked if a power cut means the systems need to be re-booted, Mr Donoghue replied: “[It] may do."
In the afternoon session, the jury heard the agreed edited summary of Ms Rose’s first interview with the police, from DC Mark Parsonson, which was attended by her solicitor and a representative of the General Optical Council.
The jury heard a description of her training and qualifications, and the type of training and instruction that is available to a locum optometrist.
In this interview statement, Ms Rose said she may not have had sufficient instruction, particularly from Boots regarding its IT equipment.
She said: “I had a holiday for three weeks, then I came back and started with Boots Opticians and Specsavers. I worked mainly in Margate and Folkestone Boots.
Specsavers and Boots have totally different systems. Margate and Folkestone even are totally different, and totally different from Ipswich. They didn’t have the fundus camera when I was working.
“Sometimes they leave instructions, sometimes they wouldn’t. Because they see you’ve worked with Boots and the records are the same, they wouldn’t give any instructions,” she said.
She added: “In Boots, I wasn’t too confident with the system. I asked someone but they didn’t show me. Usually there was someone to put the pictures up for me.”
In her statement, Ms Rose was critical of Boots Opticians’ sight test timings. She said: “Most branches think children won’t have a problem. So if a family comes with a number of children, they squeeze them into a shorter appointment. If they come for a routine check-up, they would rather think they won’t have a problem. So they think they take a fundus photograph, and if they think the child won’t have a problem they would rather squeeze in more patients.
In the statement, the jury heard what Ms Rose understood to be her duty to refer patients where she noticed a problem and her past experience of doing so.
The jury also heard Ms Rose’s general approach to conducting an eye examination, including her preference for using fundus images rather than ophthalmoscopy and slit lamp for children.
“I would conduct this test with direct ophthalmoscope, because with kids it’s difficult to use the slit lamp. I prefer to do it from a distance with the ophthalmoscope because I don’t have to come close,” she said in her statement.
The statement went through the record card from Vinnie Barker’s appointment, and Ms Rose explained what various entries meant.
She was asked if she had found anything suspicious when she checked Vinnie’s eyes using an ophthalmoscope. She replied: “Nothing suspicious with the surface.”
She added: “When I was doing the internal examination, he was showing like poor fixation and photophobia, so I was relying on the fundus photograph.
Asked as to when Ms Rose filled the form in, she said in her statement: “First I will check the fundus photograph and then taken the patient in. If the photo is not available, I will ask the patient to wait whilst I fill in the record and tell the patient if there is any pathology.
On day four the jury will read through Ms Rose’s second interview with the police, and hear from the main expert witness for the prosecution, optometrist Richard Booth. The case is expected to continue for two weeks.
5 July (cont')
Crown prosecution witnesses appear in day two of Honey Rose trial
Witnesses for the prosecution for the first-ever charge of gross negligence manslaughter against an optometrist have appeared at Ipswich Crown Court (5 July).
Under cross-examination, the jury heard from Vincent James Cox, an optometrist who worked for Boots Opticians in the Upper Brook Street practice where the defendant, optometrist Honey Rose, also worked. He said he was employed there in 2012, but was on holiday on 15 February that year when the Barker family visited the practice.
The jury heard Mr Cox explain the procedures that govern an eye test in the branch and the role of the “optical consultant,” otherwise known as the optical assistant.
The witness said that taking a retinal photograph of a child “is not a mandatory requirement... When a child comes in, the photograph is explained to the parent as just another way of record keeping. It is not always possible to get photographs. Basically...it’s a way of record keeping. The parent has the choice. Sometimes the child will decline and be backed up by the parent. It is always free for children.”
If a retinal photograph is taken, Mr Cox told the jury, it is “formally part of the examination, I myself – as an optometrist – would make a point of checking it. We would have a coding system – the letters RC and Y/N on the front of the card. That was to alert us – the optical assistant would circle Y – and that would be for payment to be taken downstairs. That’s just to make us aware, because there are some people you can’t get a photograph from – older people usually. As we get older our eyes get smaller… It was as important to record if one wasn’t taken as if one was,” he said.
“I think it is the optical consultant who decides if a photograph of sufficient quality has been taken. You quickly become experienced enough. In the first instance we are just looking for a photograph in focus. As soon as the photograph is taken, it appears on the small monitor and the external monitor,” he told the jury.
“Once the record card had been filled in and it indicated whether a retinal photograph had been taken, it was placed in a folder with the NHS forms and put inside a rack outside the optometrist’s room,” Mr Cox continued.
“We all have our own ways of working, but I would go and get that card, sign the NHS forms so I knew that had been done, if it was an existing patient just refresh – remind myself of whether there were any previous problems, then call the patient in.”
The jury also heard a summary of the steps that Mr Cox takes as an optometrist with a patient. He said that there are packs that are provided for locum optometrists working in the practice that set out the standard operating practices for Boots Opticians.
Asked to describe a slit lamp, Mr Cox told the jury that the tool “provides a stereo view of the eye. That is one disadvantage of the ophthalmoscope: it only provides a flat view. The advantage of the 3D view is that you can easily see swelling. It allows you to appreciate the depth of the disc, but primarily it is seeing swelling."
He added: “It is absolutely possible to use a slit lamp on a child patient. And they are very good to use on a child because they have such big pupils. The only difficulty with slit lamps is when the pupils are very small. Sometimes with a very small child you need to sit them on mum’s knee but there’s nothing frightening about it.”
The jury also heard testimony from the mother of Vincent – “Vinnie” – Barker, Joanne Barker.
The jury heard Ms Barker’s description of the events that took place during the visit to the Boots Opticians’ practice in February 2012 with her two children, Vinnie, and her daughter, Amber.
Describing the sight test that took place, which included retinal photography of her childrens’ eyes, she told the jury: “I can’t remember the optometrist making any comments about how the examination of Vinnie had gone. The retinal photographs were not displayed at any time during the course of the examination of Vinnie when we were all in the room together. They weren’t explained to me or shown to me on the screen at all.
She added: “The impression that I was left with at the end was that [Vinnie’s] vision and the health of his eyes was perfectly normal.”
Under cross-examination for Ms Rose’s defence barrister, Ian Stern QC, the jury heard that Ms Barker had made her statement to the police, which specifically recalled the eye test, on 15 February 2014, two years after the event took place.
Mr Stern told Ms Barker that “no one could expect you to remember everything,” and noted in her statement that she could not remember who had tested her eyes during the visit, or which member of staff had taken the retinal photographs of her children’s eyes. The jury also heard that Ms Barker could not remember if she had had her eye test or contact lens test before her children’s tests had taken place.
The defence asked Ms Barker if, at the time of the visit to optical practice, she believed a full eye test had taken been performed on Vinnie. The jury heard that she “assumed it was.” Ms Barker also said the sight test of Amber was the same as the sight test of Vinnie.
Asked to recall if there was an attempt to use the slit lamp by the defence, Ms Barker said: “I don’t recall there being any issue with it. If there was, I would recall.”
The jury heard Ms Barker confirm that Vinnie did not have an eye examination between February 2011 and February 2012 “as far as I know,” and had no symptoms on the day they visited the practice.
Ms Barker confirmed that in 2011 Vinnie had suffered from headaches, and on occasions when she woke him up “his eyes would roll forward.”
Ms Rose has pleaded not guilty to the charge of gross negligence manslaughter.
The case is expected to continue for two weeks.
Criminal trial of optometrist begins
The prosecution has set out its case against optometrist Honey Rose, who is facing conviction for gross negligence manslaughter (5 July).
In an address to the jury at Ipswich Crown Court, Prosecutor Jonathan Rees QC alleged that the optometrist could have prevented the death of eight-year-old boy Vincent – "Vinnie" – Barker, who died in July 2012, if Ms Rose "had done her job properly."
In a post mortem, it was revealed the cause of death was hydrocephalus – water on the brain – which led to his collapse and eventual death.
The prosecution explained that approximately four months prior to his death, Vinnie and his sister were taken for an eye examination at Boots Opticians. Ms Rose was a locum optometrist at the practice and carried out the eye examination.
The jurors were told that "like all optometrists, [Ms Rose] owed a duty of care to patients to deal with them to the standard of a reasonably competent optometrist. That included carrying out a competent examination of the eye and carry out an urgent referral if any problem detected."
The prosecutor explained that at the time of Vinnie’s eye examination there were "obvious abnormalities in both of Vinnie’s eyes," referring to fundus photographs taken by another member of staff just before the boy was examined by Ms Rose. These images showed that the back of each eye was swollen because of hydrocephalus. The jury were told that the parties agreed that Vinnie had swollen optic discs at the back of both of his eyes.
Mr Rees told the jury that the abnormalities "would have been obvious to any optometrist who had examined his eyes. If they had been examined, they couldn’t be missed, and if they had been noticed, he would have been urgently referred because papilledema is known to be a fatal condition."
"Vinnie wasn’t referred for further investigation as he should have been. Indeed it was the defendant’s assessment that he needed no further treatment at all," he said.
The jury heard from the prosecution that if Vinnie had been referred, the evidence showed that the hydrocephalus would have been identified and his condition treated by a neurosurgeon. Mr Rees asserted that this treatment would have prevented Vinnie’s death.
Mr Rees added: "The defendant’s failure to detect the swelling of his optic discs and refer Vinnie on was grossly negligent. Her conduct was so bad in all the circumstances that it fell so far below the standard to be expected from a reasonably competent optometrist that it was criminal."
Hearing of Ms Rose’s professional background, the jury was informed that she qualified as an optometrist in India in 2005.
"She came to the UK and passed the exam which allowed her to practice here, and she registered to practise with the General Optical Council in 2010," the prosecutor said.
The jury were also given an explanation of the role of an optometrist, and how it differs from a dispensing optician. "Optometrists are under a statutory duty to perform an examination of the internal structures of the eye by the use of an ophthalmoscope” with the intention to "detect signs of disease, injury or abnormality," Mr Rees explained.
Focusing on the optic disc, which the jury were told was "at the heart of this case," jurors were shown a diagram of the anatomy of the eye, making the case that the optic disc was swollen in Vinnie’s eye because of his raised brain pressure.
To establish the prosecution’s case that Ms Rose breached her professional duty of care, the jurors were told that they would be hearing expert testimony from optometrist Richard Booth. Ms Rose has plead not guilty to the charge.
The case is expected to continue for two weeks.
OT will continue to cover this case on a daily basis, including the arguments of the defence.