Wrongly reassured

Miss R was 28 years old and in a stable relationship. She worked shifts in a call centre and found that she was forgetting to take her oral contraceptive pill at the correct time. She had tried the IUCD in the past and, after she developed an infection and it had to be removed, she was not keen on trying that again.

After discussing potential options with her GP, Dr F, she decided that she would like to try depot injections. As part of the consultation and counselling, she was warned that she could expect some changes to her vaginal bleeding pattern, particularly during the first injection cycle.

When she attended for her third injection, six months later, she told the nurse that she was experiencing some light vaginal bleeding at times. She said that it didn’t cause her any distress and she enjoyed the freedom that the injection gave her. Particularly with her irregular hours, she didn’t have to worry about setting her alarm to take the contraceptive pill. The nurse reassured Miss R and told her that some light bleeding was common with the injections.

There was no record made of the need for any further medical review if the bleeding did not stop.

Over the next 18 months, Miss R made several mentions to nursing and medical staff that she was still having irregular vaginal bleeding. There were brief records made of three such discussions. Two involved discussions between the nurse and the duty doctor at the surgery and at no point was a pelvic examination undertaken, or any more detailed gynaecological history recorded. One entry in the records implied that previous records had not been looked at by the doctor involved.

Miss R continued with the depot injections and, nearly two years after she received the first one, she made an appointment with Dr F. She explained that the irregular bleeding had never stopped and, although it had originally only been three or four times per month, now it was on an almost daily basis. Dr F made an appointment for Miss R to have a cervical smear. The smear showed severely dyskaryotic cells and she was referred urgently to gynaecology. Miss R had an invasive cervical carcinoma and a radical hysterectomy was carried out.

A claim was made and expert opinion found the case to be indefensible. She successfully sued the practice for a high sum.

Learning points

• Clinicians managing women with any unusual bleeding pattern, especially while using progesterone-only injectable (POI) contraceptives, should take a full history and conduct an appropriate gynaecological examination. See Faculty of Sexual and reproductive Healthcare Clinical Guidance: Progesterone Only Contraception, Clinical Effectiveness Unit, Nov 2008 (updated June 2009). 
• While spotting and mild vaginal bleeding is common in the first cycle of POI, if this becomes persistent, or the bleeding occurs after a period of amenorrhoea, then exclude gynaecological problems that are clinically indicated. See UK Selected Practice Recommendations for Contraceptive Use.
• If the medical notes are available to the clinician and they are not reviewed for an ongoing problem, it is very difficult to defend a claim or complaint. 
• Having a look at a patient’s previous attendances can give invaluable clues to diagnosing a new problem. 
• As care is often team-based, involving GPs, nurses, nurse practitioners, it is essential to have a protocol in place where anything untoward is flagged. 
• It is important to listen carefully to patients’ concerns, especially symptoms mentioned as a “by the way” comment. 
• Remember the red flags for referral for gynaecological cancers:
  • Consider urgent referral for a woman with persistent intermenstrual or post-coital bleeding with a normal pelvic examination. 
  • If lesions suspicious of cervical or vaginal cancer are seen on speculum examination, a cervical smear result is not needed before referral and a previous negative smear test is not a reason to delay referral (NICE guidelines).
  • The first symptoms of gynaecological cancer may be alterations in the menstrual cycle, intermenstrual, postcoital or post-menopausal bleeding, or vaginal discharge. If a patient reports any of these symptoms, the doctor should undertake a full pelvic examination, including speculum examination of the cervix.
• Also see NICE guidelines (plus regional guidance).