A 10-year ordeal for the family of Vinnie Barker concluded last week as the General Optical Council’s fitness to practise committee ruled that optometrist Honey Rose should be erased from its registers for her part in the events that led to his tragic death. But how did the case start and how did it develop?
February 15 2012
Vinnie Barker attends Boots Opticians in Ipswich. He, his sister and his mother, Jo Barker, were all examined by optometrist Honey Rose, who qualified in India in 2005 and registered in the UK in 2010. Images captured before the exam by another member of practice staff showed the optic nerve and retinal blood vessels in Vinnie’s eyes were abnormal and suggested papilloedema, typically caused by increased intracranial pressure, by a build-up of fluid in the brain. Crucially, the correct images were not viewed by Rose.
July 13 2012
Vinnie Barker is taken ill at school and sent home. He passes away later that evening at home. A post-mortem revealed the cause of death as hydrocephalus – build-up of fluid in the brain.
March 2013
Rose is suspended for 18 months after a GOC fitness to practise committee alleged that she failed to notice abnormalities in a patient’s eye. The meeting was held in private and full details were not revealed due to an on-going police investigation.
October 2014
Rose is told by the GOC that she can return to practice under conditional registration after an 18-month suspension. The committee said it was not a case of alleged attitudinal failure, which would be difficult to demonstrate remediation, but a case of alleged incompetence in a single case and an isolated area of practice. In its view, she had addressed the area of clinical practice of concern and was not a current danger to the public.
August 2015
The GOC imposes an interim suspension order on Rose, restricting her from practice.
September 2015
Rose appears at South East Suffolk Magistrates Court in Ipswich to be formally charged with manslaughter by gross negligence. No plea was entered, and she is granted unconditional bail.
April 2016
At a hearing held at the Old Bailey, Rose denies the charge of manslaughter by gross negligence. A trial is scheduled for July.
Criminal proceedings
July 4-15 2016
The landmark trial begins at Ipswich Crown Court. It is the first time an eye care professional has faced a charge of manslaughter relating to clinical failings. For the prosecution, Jonathan Rees QC tells the jury that there were ‘obvious abnormalities’ in both of Vinnie’s eyes, which would have been obvious to any reasonably competent optometrist and if they had been examined, Vinnie would have been referred and would still be alive.
During the trial, the jury heard from expert witnesses and staff from the Boots Opticians practice where Vinnie was seen in 2012. Optical consultant Carol Cocker said her role included capturing retinal images but had been given no formal training about identifying abnormalities. Despite this lack of training, she would still mention abnormalities to the optometrist during handover, but not say anything to the patient. Cocker could not recall if she captured Vinnie’s images, but did recall there were often technical problems with the fundus camera when she worked at the practice.
In her evidence, Rose (pictured, left) recalled that Vinnie had been a challenging patient and that she could not complete a full examination of the back of the eye with an ophthalmoscope due to him not looking where he was instructed. She said he was showing signs of ‘slight photophobia’ and recorded this on the record cards.
Rose said she viewed images showing a normal central retina and optic nerve prior to the exam, but they belonged to a different patient. She recalled a police interview in 2013, where she was shown Vinnie Barker’s retinal images from February 2012 but attested that she had not seen the photos prior to the interview. At the trial, she said that had she seen the correct photos, she would have made an urgent referral.
On July 15, Rose is found guilty of manslaughter by gross negligence. The jury took three hours and 21 minutes to record a unanimous verdict.
August 26 2016
Rose is handed a two-year custodial sentence, suspended for two years. She indicates that she will seek leave to appeal.
May 13 2017
Rose’s appeal is brought before the Criminal division at the court of appeal.
July 31 2017
A panel of three judges overturns the 2016 conviction of Honey Rose. Sir Brian Leveson, sitting with two other judges, said the court had concluded that ‘in assessing reasonable foreseeability of serious and obvious risk of death in cases of gross negligence manslaughter, it is not appropriate to take into account what the defendant would have known but for his or her breach of duty.
‘The implications for medical and other professions would be serious because people would be guilty of gross negligence manslaughter by reason of negligent omissions to carry out routine eye, blood and other tests , which, in fact, would have revealed fatal conditions. Notwithstanding, that the circumstances were such that it was not reasonably foreseeable that failure to carry out such tests would carry an obvious and serious risk of death.’
They added: ‘This decision does not, in any sense, condone the negligence that the jury must have found to have been established at a high level in relation to the way that Ms Rose examined Vincent and failed to identify the defect which ultimately led to his death.
‘That serious breach of duty is a matter for her regulator; in the context of this case, however, it does not constitute the crime of gross negligence manslaughter.’
Vinnie’s parents, Ian and Jo Barker, said: ‘We are understandably devastated; we feel that the conviction of manslaughter by gross negligence should have been upheld. We remain in no doubt that if Honey Rose had not breached her duty of care to our son he would still be with us today.
‘We have endured five years of harrowing investigations and court proceedings. To be left now, putting our faith in the General Optical Council and their responsibility to uphold the standards of their profession to ensure that Honey Rose is unable to resume any practice in optometry.’
October 24 2017
An application to challenge the acquittal of Honey Rose at the Supreme Court is turned down by a panel of judges headed up by Sir Brian Leveson. The prosecution had claimed the law on gross negligence manslaughter was ‘not satisfactorily clear’ and needed to be considered by leading judges.
Fitness to practise case
November 2017
The GOC receives disclosure from the criminal investigation.
July 20 2020
Fitness to practise hearing begins. The committee determined that Ms Rose failed to carry out an adequate internal eye examination on Vinnie Barker and viewed the wrong retinal image. There were also record keeping failures. Panel chair Graham White said that the committee did not consider the departure from the relevant professional standards to be sufficiently serious to warrant erasure from the register. ‘Erasure is a sanction of last resort and should be reserved for the category of cases where there is no other means of preserving the wider public interest,’ he said. Rose receives a nine-month suspension and signals her intent to return to the profession when the sanction lapses.
Association of Optometrists legal director, Ella Franci, says: ‘It has been a long and difficult process for our member, Ms Rose, but ultimately we feel that it is a good result for her and the AOP’s legal team.
‘Ms Rose’s account of what happened was accepted, and she was found to have sufficiently remedied any past misconduct identified by the FTP Committee. Although disappointed to remain suspended for nine months, Ms Rose is looking forward to returning to the profession she loves, with the ongoing support of the AOP.’
Ian and Jo Barker said: ‘The GOC’s decision is devastating for us, our family and friends, and the professionals that have continuously supported us. We do not believe this decision is in the best interest of the optometry profession or, more importantly, the public interest.’
The GOC’s press release includes the unusual inclusion of information relating to the role of the Professional Standards Authority (PSA) and in reviewing GOC fitness to practise rulings.
January 26 2021
An appeal is made to the High Court by the PSA against the GOC’s decision to suspend Rose for a period of nine months. The PSA says it is concerned that the decision was not sufficient to protect the public and asks the High Court to quash the committee’s findings as it took the wrong approach to impairment and sanction, and wrongly decided not to conduct a review before the period of suspension ended.
November 3 2021
The PSA’s appeal against the GOC’s fitness to practise committee’s decision on Rose is upheld by the Royal Courts of Justice and referred back to the regulator.
July 4-26 2022
Remitted substantive fitness to practise hearing begins. The panel notes grave errors and dishonest record keeping. Chairwoman Jayne Wheat said: ‘Rose abandoned her statutory duty to conduct a full internal examination of both eyes and relied on incorrect central retinal images because she had failed to identify the correct patient’s images.
‘This was serious in its own right. What made the situation worse was Rose’s unexplained recording of misleading, and on one occasion dishonest information.
‘The committee has clearly identified that Vinnie was put at an unwarranted risk of harm.’
For the first time, Rose apologises to the Barker family. In a statement, Rose says: ‘I would like to apologise to Vinnie and his family, and to everyone who has been affected in any way in this case, for my failings. I didn’t check the name on the photograph but would now. I would never make a record in the same way as I did for Vinnie’s periphery again.
‘I made a misleading and dishonesty (sic) entry in relation to the periphery. I recorded that the periphery was normal but the periphery had not been examined as I had been unable to complete ophthalmoscopy and it was not visible on the photographs.
‘I therefore had no observable basis for writing that it was normal. I had made an assumption.
‘I understand that the way I made the record would have given future practitioners the impression that I had examined the periphery when in fact I had not done so. If I was unable to examine the periphery, for whatever reason, I should have made this clear on the record and noted why this was, so that other practitioners would have known (sic) what had happened.’
Jo Barker tells Optician that the family is relieved at the outcome, but their fundamental concern is the length of time and the extreme lengths they had to go to in order to achieve a sense of justice for Vinnie.