Part 2 —continued

Governance Failures Embedded in the 2026 Assessment

This section examines the governance failures created by the 2026 assessment. It explains how the use of an inappropriate clinical method, the absence of specialist oversight, and the introduction of clinically impossible findings into the record produced systemic risks that affected safety, continuity of care, and the reliability of the clinical narrative.

The issues identified in the 2026 assessment are not limited to clinical error. They represent system‑level governance failures that affect safety, continuity of care, and the reliability of the clinical record. When a vulnerable adult with a long‑established neurological impairment is assessed using an inappropriate method, the consequences extend beyond the appointment itself.

Lack of specialist oversight

The young person’s condition has always required:

• specialist neuro‑visual assessment

• functional‑vision evaluation

• clinicians trained in neurological impairment

The 2026 assessment was carried out without specialist involvement and without reference to the established clinical baseline. This breaks continuity of care and removes the safeguards that specialist oversight provides.

Failure to access or consider the 30‑year clinical record

A coherent, long‑term record existed. It documented:

• permanent neurological injury
• non‑fluctuating impairment
• consistent vertical nystagmus
• stable functional‑vision limitations

The 2026 clinician did not access, reference, or replicate this baseline. This is a governance failure because continuity of information is essential for safe decision‑making.

Use of an inappropriate clinical framework

Routine optometry was used to assess a neurological condition. This is not a matter of preference — it is a mismatch between:

• the nature of the impairment, and
• the method used to assess it.

Governance frameworks require that assessments are:

• clinically appropriate
• methodologically sound
• aligned with the individual’s known condition

The 2026 assessment did not meet these standards.

Creation of an inaccurate clinical record

By describing permanent neurological features as:

• “intermittent”
• “variable”
• “inconsistent”

the 2026 letter created a clinical narrative that is:

• misleading
• clinically impossible
• inconsistent with the long‑term record
• unsafe for future decision‑making

In governance terms, this is a record‑keeping failure with direct safeguarding implications.

No recognition of safeguarding responsibilities

Safeguarding requires:

• accurate information
• recognition of vulnerability
• understanding of functional limitations
• continuity between professionals

The 2026 assessment:

• minimised the impairment
• obscured risk
• contradicted the established baseline
• reduced visibility of functional‑vision needs

This undermines the ability of other professionals to make safe decisions.

Absence of clinical justification for contradictory findings

When a clinician reports findings that contradict decades of specialist evidence, governance requires:

• justification
• explanation
• rationale
• reference to methodology

None were provided.

The contradictions were presented as fact, without acknowledging that the assessment method was not capable of measuring the impairment.

Why this matters

Governance frameworks exist to prevent exactly this scenario:

• a vulnerable adult
• with a permanent neurological impairment
• assessed using an inappropriate method
• producing clinically impossible findings
• which then enter the record
• and influence future decisions
• without specialist oversight
• and without safeguarding consideration

The 2026 assessment did not meet the standards required for safe, accurate, or appropriate clinical practice.

It represents a systemic governance failure, not a simple clinical disagreement.

To understand how the 2026 assessment diverged so sharply from established evidence, the next section presents the full clinical timeline from 1993 to 2026. This chronology demonstrates the stability of the impairment, the consistency of specialist findings, and the moment the system failed.

Next

2.3A — The Clinical Timeline (1993–2026)

Design & Copyright Owner Maureen Booth-Martin (MBM) © All rights reserved