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When normal is wrong

01 May 2013

Mr B, a 35-year-old businessman, consulted Mr L, a urologist, over the telephone requesting a vasectomy. Mr B had been married for 12 years and had three children with his wife, aged seven, four and two. Mr L explained the procedure briefly over the telephone to Mr B, stating that there was a slight risk of infection and bleeding from the procedure and a very slight risk of chronic scrotal pain. Mr L then sent Mr B the hospital admission form and the consent form, to bring back with him on the day of the operation.

Mr B was admitted to the ward and only met Ms Q, the urologist who would perform the operation. In that short visit, Ms Q introduced herself to Mr B, checked his signature on the consent form, and told Mr B he should be out of hospital in a few hours’ time.

On discharge later that day, Mr B was advised to get a sperm count organised by his doctor in 12 weeks’ time. He claimed later that he was not given any practical advice on contraception, nor told that there was a risk that the vasectomy might not have worked. Ms Q did not see Mr B after the operation; instead it was the nursing staff that discharged Mr B and gave him advice regarding his sperm count check.

GP Dr X saw Mr B in clinic and was surprised to hear about the operation but still requested a path lab test for his semen analysis, although he failed to label that it was post-vasectomy. Dr X advised Mr B to contact the urology clinic for the results.

Mr B contacted the clinic but could not get hold of any of the doctors. The secretary mentioned that the report said “normal”, which Mr B interpreted as meaning that the operation had been successful.

Unfortunately, Mrs B became pregnant and only then it was made clear that Mr B’s sperm count was normal. Mr B made a claim against all doctors involved. The case could not be defended and it was settled for a moderate sum.

Learning points

  • Vasectomy is one of the technically simplest urological procedures and yet one of the most litigious. While the procedure might be simple, the consent process is not. Informed consent is best gained in person rather than over the telephone and ideally should be performed by the person performing the operation.
    If it is gained a few days or more before the procedure, consent should be confirmed on the day of the procedure by verifying the patient’s understanding of the procedure. Going through the operative risks of the procedure is not sufficient. The failure rate of vasectomy, either due to failure to remove adequate sections of both vasa or recanalisation, albeit small, is of crucial significance, and must be mentioned and documented.
  • The patient must also be told that it takes around 12-14 weeks on average for the sperm to be non-motile or absent after vasectomy, and thus two separate sperm samples should be provided at these time intervals, and contraception used until the patient receives the ‘all-clear’ from these samples. These sperm samples should be marked as post-vasectomy so the processing laboratory understands that the desired result would be to have no sperm or few non-motile sperm.
    If the patient’s GP is expected to send these samples then a discharge letter explaining this plus the procedure should be sent to him/her, so that he/she is aware of the situation. The results of the sperm samples should also be sent in writing to the patient’s GP as well as the patient with a letter from the urologist who performed the procedure stating the ‘all-clear’ or otherwise. If viable sperm are still present, the patient should be advised to continue contraception and provide a further sample four weeks later.
  • Results should not be given over the telephone by non-medically-trained staff, to avoid potential miscommunications as happened in this case.
  • This case illustrates the commonest reason for medical claims – poor communication. There was poor communication at multiple stages: during the consent process, between urologist and patient after the operation, between urologist and GP after the operation, between GP and sperm laboratory, and between patient and urology secretary. While each of these errors might appear small in isolation, together they added up to an undesired outcome.