Jotting it all down

Mrs T, a 40-year-old mother of one with an extensive gynaecological history, had suffered with menorrhagia secondary to fibroids for most of her adult life.

This had failed to respond to both medical treatment and a myomectomy. Mrs T's one pregnancy was uneventful, but she elected for a caesarean section in view of her persistent problems with fibroids.

Mr Y ensured he had carefully documented the procedure and had included a detailed description of his findings, with clear writing and diagrams

Following the birth of her son, her menorrhagia returned and she began to experience more persistent abdominal and pelvic pain, which was investigated and attributed to postoperative adhesions.

After several years of discomfort, she approached her GP for advice regarding surgery and he referred her to consultant gynaecologist Mr Y. Mr Y discussed the options with her and she decided that, as she no longer wished to have any more children, an abdominal hysterectomy offered a more definitive approach and was the best method for her to relieve the continued symptoms.

Mrs T attended Mr Y’s preoperative clinic, where she was assessed by the nursing staff and given an explanation of the procedure by one of the junior doctors. Mr Y performed the operation a week later. It was a difficult procedure due to inflammation, adhesions, and large and friable blood vessels around the bladder, due in part to her previous history.

However, no immediate complications were noted intraoperatively. Mr Y ensured he had carefully documented the procedure and had included a detailed description of his findings, with clear writing and diagrams.

The experts reviewed the notes and did not consider that there was negligence, since ureteric injuries are a recognised complication of hysterectomy

Mr Y had not checked the notes prior to the operation regarding what complications had been discussed or what consent had been taken. There was no documentation regarding identification of the ureter.

Mrs T started suffering from dysuria almost immediately, but didn’t report it straight away. Further investigations, including an IV pyelogram, demonstrated a blocked ureter which had led to hydronephrosis.

The urology team on call took Mrs T to theatre and successfully reimplanted the ureter onto the bladder, restoring urine flow. There were no long-term consequences.

Mrs T made a claim against Mr Y for damaging her ureter during the hysterectomy. The experts reviewed the notes and did not consider that there was negligence, since ureteric injuries are a recognised complication of hysterectomy, especially when previous pathology may alter the expected anatomical course of the ureter. However, they did agree that Mr Y was liable for a failure to warn the patient of the risk of this complication.

It was also argued that this led to a delay in diagnosis and that if the patient was aware of the possibility of ureteric damage then she would have reported her urinary symptoms earlier. The claim was settled for a moderate sum.

Learning points

Valid consent is the responsibility of the health professional who is undertaking the procedure

  • Appropriate informed consent should include: an explanation of the investigation, diagnosis or treatment; an explanation of the probabilities of success, the risk of failure; side effects and complications.
  • Valid consent is the responsibility of the health professional who is undertaking the procedure; this can be delegated to a member of staff who has sufficient knowledge to give the patient all the information they need to make an informed choice. Mr Y should have checked what was documented in terms of the scope of consent preoperatively and addressed any gaps.
  • Good quality notekeeping is essential, and this must include all aspects of the consultation including consent.
  • Surgical complications happen. Damaging the ureter during hysterectomy is a recognised complication of the procedure with an incidence around 1%.1 The occurrence of a complication does not necessarily equate to negligence.
  • When things do go wrong it is important to deal with the situation in the right way as quickly and efficiently as possible. Provide the best possible care to resolve the problem and be open and transparent with the patient.

References

1. Chelmow D, Aronson MP, Wosu U, Intraoperative and postoperative complications of gynecologic surgery, in: DeCherney AH, et al (eds), Current Diagnosis & Treatment: Obstetrics & Gynecology (10th edn), New York, NY: McGraw-Hill Medical (2007)

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