How to reduce risk in gynaecology? Insights from litigation

Across a clinician’s career, unexpected professional challenges can arise. Even a single complaint or claim can be professionally draining, emotionally exhausting and disruptive to the care you want to provide.

At Medical Protection, we support members through criminal, disciplinary and regulatory investigations, complaints, ethical dilemmas and clinical negligence claims, and we see first hand the toll these can take. 

Our involvement is not confined to moments when difficulties have already occurred. Just as clinicians aim to prevent symptoms before they escalate, at Medical Protection we believe a medical defence organisation should do the same. We work to help you avoid medicolegal problems long before they reach the stage of a complaint or claim. One of the most effective ways to do that is by learning from real cases: examining where problems most often begin, recognising early indicators of risk, and applying those insights to support safer, more confident everyday practice. 

We recently carried out a detailed review of clinical negligence claims involving consultant gynaecologists working in private practice worldwide (excluding antenatal screening and obstetric care). This analysis has revealed clear, recurring themes that offer valuable insight into where risks most commonly arise. 

By sharing these findings, we aim to give members in Hong Kong practical, evidence‑based learning that can strengthen clinical practice, enhance patient safety and reduce exposure to claims.

Surgical technique 

The most common outcomes due to alleged inadequate surgical technique were bowel perforation (predominantly small bowel), nerve injury, arterial injury and bladder/ureter injury. Subsequent to these injuries, concerns were often raised that the injury was not identified during the operation, resulting in a significant delay in treatment and poorer outcomes or more complex treatment needs. In addition, the choice of operation or surgical approach (for example open vs laparoscopic) was also highlighted in several claims particularly when more conservative options were potentially available.

Specialist involvement 

In some cases, the gynaecologist was criticised for not involving other specialists during the assessment or treatment of the patient. The most common allegation related to the failure to involve a general surgeon when the patient presented with a complex surgical history pre-operatively, or during the operation when complications occurred. This highlights the importance of strong interprofessional communication at all levels as this could in some cases be due to a simple failure in communication regarding when the pre-operative assessment or operation was taking place, or inadequate resource planning to ensure the availability of colleagues in case of emergencies.

Post-operative care 

Criticism of post-operative care mainly arose from failure to identify the complications of surgery (commonly bleeding, bowel perforation and infection) in a timely fashion, often due to inadequate monitoring or failure to act on clinical signs or investigations (raised CRP, hypotension, abdominal pain) leading to a delay in treatment. In some cases, this could be due to inadequate clinical assessment by an individual but could also result from insufficient instructions being provided to the nursing team regarding the frequency of monitoring or when to escalate a patient’s care. Availability of the consultant or difficulty in contacting the consultant post-operatively also featured within several claims.

Informed Consent 

Clinicians are increasingly aware of the necessity to provide adequate detail of the risks and benefits of any procedure or treatment they are providing. Whilst concerns still arose that the patient was not warned of specific risks or complications, the expectation now is that the consent should be more tailored towards the individual patient. For example, advising a patient of increased risks of complication/infection due to regular intake of immunosuppressant medication. Another risk factor in relation to consent was the failure to advise of alternative options, the option of receiving no treatment, or the offer of a second opinion. Finally, in investigative procedures (for example, laparoscopy for diagnosis and treatment of endometriosis) it became increasingly clear that a detailed and documented consent procedure was required, including not only the risks and benefits of the original investigative procedure, but also any subsequent treatment that may be required during the operation.

Documentation 

Not unexpectedly, documentation was often a critical factor in the decision to either settle or defend a claim, as clear documentation can clearly illustrate what actions or discussions have or have not taken place. In many cases there was often an alleged failure to document in sufficient detail, the consent process (options offered, risks/benefits advised), reasons for choosing a particular procedure, the operation note, or evidence of adequate post-operative review/assessment. Simple errors in documenting test results or passing on incorrect results to colleagues, particularly within the IVF arena, also featured within these claims.

Reducing your risk 

At Medical Protection, we are very aware that it can be incredibly distressing to discover that a patient is unhappy with their care to the extent that they wish to bring a claim against you. Our experienced team are here to support our members through every step of that process should that happen, however there are several steps gynaecologists can take to minimise their risk of a claim or adverse incident occurring:

• Be alert to the possibility of adjacent organ injury peri-operatively, particularly small bowel injury, and have a low threshold to involve specialist colleagues at an early juncture. 

• Consider and discuss all treatment options with the patient, particularly more conservative approaches when they are appropriate. 

• Effective interprofessional communication is essential to reducing your risk and safeguarding patient welfare from the first consultation to discharge. Ensure you have a clear and standardised process in place for informing any specialists involved of when and where their input will be needed, and have a low threshold for involving them - particularly in the pre-operative assessment of complex patients. 

• Document a clear post-operative plan of when and how you should be contacted if any complications arise, how often observations should be undertaken, and which other specialists should be involved if required. 

• Undertake a thorough consent process: ensure the patient is aware of the risks, benefits and complications of the procedure and any alternative or subsequent treatment options. Consider if the consent process needs to be tailored to that individual, depending on any comorbidities, medications or social history. Ensure you are familiar with and adhere to the Medical Council of Hong Kong’s guidance on consent within the Code of Professional Conduct.

• Consider the use of supporting information via patient information leaflets or digital resources to ensure full patient understanding. Use of these should also be documented in the records and regularly checked to ensure they are up to date and still fit for purpose.

• Ensure you have included sufficient detail in your records, particularly in relation to treatment options discussed, the consent process, operative notes and post-operative plans and reviews.

Medical Protection has resources available to support members in reducing risk through each of these steps including improving communication with patients and other medical professionals and enhancing record keeping. 

Case study 

Mr T, a consultant gynaecologist, saw patient A in their private practice in relation to persistent menorrhagia and ovulation pain. Patient A had an extensive history of abdominal procedures due to Inflammatory Bowel Disease and had recently been diagnosed with an ovarian cyst.

Mr T had discussed the different options available for treatment with Patient A at length, explaining the risks and benefits of each, with the patient deciding that a total abdominal hysterectomy and bilateral salpingo-oophrectomy was their preferred choice. Due to their abdominal surgical history, Mr T arranged for Patient A to see Miss B, a General Surgeon for pre-operative assessment. Miss B advised of the potential for multiple adhesions to be present and agreed she would be willing to assist if required.

Mr T planned the surgery for a Wednesday at the private hospital, assuming that Miss B would be present as she usually had an operating list there on a Wednesday but didn’t inform Miss B of the specific date in advance to ensure her availability.

During the operation Mr T found loops of small bowel firmly adhesive to the peritoneum and the uterus and had difficulty identifying the left ovary. At this stage Mr T called Miss B for assistance, but there was no reply, due to Miss B being on holiday. Mr T decided not to call another general surgeon and continued with the operation. During the operation the small bowel was perforated but not identified at the time. The perforation was diagnosed post-operatively by which time the patient required a temporary ileostomy and prolonged ICU stay.

A claim was brought against Mr T for proceeding with no general surgeon available, failure to call a general surgeon when adhesions were discovered, and failure to work within the limits of their competence.

The claim was settled and Mr T reflected and recognised that he would have a lower threshold for involvement of a general surgeon in similar circumstances in future, and that clear documentation of the process required to confirm their attendance was essential.