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Missed opportunities

01 January 2011

Miss R was a 23-year old woman who came to see her GP worried about the possibility of an unplanned pregnancy. Her last period was seven weeks ago. She had had a previous termination at aged 16 and had found it a very stressful experience. Miss R was very upset and asked her GP if she could have a termination of pregnancy (TOP).

Dr W took a medical history. Miss R tearfully explained that she had had a termination once before and had been to a GUM (genitourinary medicine) clinic when she was much younger. There was no record of this in Miss R’s notes. Dr W spent time talking through the process of a termination with Miss R and exploring her thoughts about the pregnancy. Miss R was certain that she wanted a termination and had discussed this with her partner.

Dr W referred Miss R for a TOP. Not unusually, Dr W hadn’t received any letters from the GUM clinic and, as it had been more than five years ago, Dr W didn’t document this information in her own notes. She did not ask Miss R why she had attended the GUM clinic, or contact the GUM clinic with Miss R’s consent to find out the reason for her attendance.

The TOP was performed a week later. Miss R wanted a long-acting form of contraception and so an intrauterine device was inserted. Miss R did not have an STI screening and the doctor did not flag the GUM attendance with the TOP doctor.

Three weeks later, Miss R attended the GP surgery with discomfort passing urine and general lower abdominal discomfort. She was seen by Dr F, who reassured her that it was normal to have some discomfort after a termination and that it should pass. However, in the following month, Miss R attended surgery twice more, again with the same symptoms, and saw a different doctor each time. Both doctors performed urine analysis and MSSUs, but these proved negative.

Each time Miss R saw a doctor, no record was made in the notes of her being examined. Later, Miss R confirmed that she had not been examined by any doctor.

A few weeks later, Miss R continued to have worsening lower abdominal pain, despite regular painkillers, so once more she attended her GP.

On this occasion she was seen by Dr W, who performed an internal examination and thought she could feel a pelvic mass. Dr W was worried about an ectopic pregnancy; however, a pregnancy test was negative. She suspected a complication of the termination procedure and discussed her findings with the on-call gynaecology registrar, who arranged a clinic appointment for early the next morning.

Later that day, however, Miss R’s pain became much worse and she called an ambulance. In the emergency department she was diagnosed with possible pelvic inflammatory disease. Miss R was taken to the operating theatre. Extensive pelvic inflammatory disease was confirmed, with tubo-ovarian abscesses. The inflammation was extensive, surrounding all structures, and Miss R required a bilateral salpingooophorectomy. Chlamydia testing was positive.

Miss R made a claim against all the GPs involved in her care for the delay in diagnosis and her resulting infertility.

Expert opinion

Expert opinion agreed that Miss R’s diagnosis had been significantly delayed due to inadequate patient records and delayed examination. Earlier testing and treatment for sexually transmitted infection would have prevented the complication of pelvic inflammatory disease and subsequent removal of both the ovaries and fallopian tubes, which resulted in infertility. The claim was settled for a substantial sum.

Learning points

  • Documentation of relevant history is vital for good continuity of care, where a patient may not see the same doctor twice. In this case, attendance at a GUM clinic was significant and should have been explored further and recorded in the notes.
  • When seeing a patient with persistent symptoms, it is important to make a complete reassessment and exclude serious underlying pathology.
  • When seeing a patient who has seen other doctors before, it is good practice to take the history and/or examine the patient again, to pick up new information and keep an open mind to alternative diagnoses. Do not presume the last doctor was necessarily on the right track.
  • Most GUM clinics do not routinely inform doctors about patient attendance, so it is important that you take a full history from the patient.
  • Failure to examine the patient will often render a claim indefensible.
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