Record keeping plays a major role in the development of this case, which sees GP Dr O receive a clinical negligence claim following the insertion of an IUCD. By Conrad Dixon, Claims Manager, Medical Protection.
Mrs C was eight weeks postpartum when she attended her GP Dr O to discuss contraceptive options, to include an IUCD. She was given some time to consider the options and later returned to say she would like to proceed with a copper IUCD. Mrs C then attended Dr O’s practice for insertion of the device.
Mrs C had a further discussion about the options and Dr O explained the risks using a two-dimensional model of the uterus, demonstrating these risks including perforation, pelvic inflammatory disease, pain, bleeding, discharge and lost threads. Dr O later recalled it would have been her normal practice to take particular care to counsel about the risks of perforation and expulsion, as these complications can be more common if an intrauterine device is inserted eight weeks postpartum.
Mrs C was offered further time to reflect but confirmed she was keen to proceed with the procedure and had a newborn baby at home. Dr O fitted the copper IUCD, having sounded the uterus, and performed a bimanual examination post-insertion, which was normal. Mrs C complained of pain following the procedure and was prescribed analgesics. Dr O asked her to come back in six weeks for review, or sooner if she had any difficulty with bleeding or pain.
Dr O made a full note in the records detailing their discussion, consent, the procedure and her follow-up advice. Following the procedure, Mrs C remained on the premises under the observation of a nurse until she was ready to leave. Dr O did not have any further involvement in the patient’s care.
Mrs C’s pain worsened overnight and the following day she attended hospital. She presented with abdominal pain and an x-ray revealed the IUCD had migrated and was visible in the right iliac fossa. Mrs C was hospitalised for surgical laparoscopic removal of her IUCD.
Mrs C made a clinical negligence claim against Dr O, alleging:
• There was a failure to arrange a referral to hospital for immediate assessment, and that Dr O’s follow-up was inadequate.
• Mrs C’s symptoms at the GP surgery of pain during the procedure were suggestive of a uterine perforation, which Dr O had failed to diagnose and manage.
• That Mrs C had asked Dr O to stop the procedure due to pain and yet she proceeded and did not stop. Mrs C said she fainted from the pain during the procedure.
Dr O had a good recollection of the consultation, and had fully consented Mrs C for the procedure, including the risk of perforation. The discussion in relation to consent was fully recorded in the notes. Following the procedure, Dr O performed a bi-manual examination and threads were palpable; she recorded in the notes there wasn’t any sign of a perforation.
There was a factual dispute in relation to the recollections by both Dr O and Mrs C of the procedure and discussions. Dr O accepted Mrs C had asked her to stop the procedure, but recalled that this was at the end of the procedure. Dr O was adamant that the patient did not faint, as if she had she would have abandoned the procedure.
Dr O had made excellent notes documenting the discussions in relation to the rationale for the procedure, consent and risks including the risk of perforation, nature of the procedure and her follow up advice. She was an experienced practitioner in the area of women’s health and was also experienced in this particular procedure, and kept up to date with best practice and had undertaken recent training regarding the procedure.
How did Medical Protection assist?
The initial expert GP report was critical of Dr O’s treatment. This report supported the allegations that had already been made. In agreement with Dr O, Medical Protection obtained our own expert evidence, which was supportive of the treatment.
This was a UK based case: a letter was sent to Mrs C’s solicitors based on Dr O’s evidence, refuting the claim and setting out the basis for this with specific reference to Dr O’s recollection of the procedure and the medical records. Mrs C’s solicitors were also provided with details of Dr O’s CV, training and experience in relation to this procedure.
After issuing our letter of response, which refuted the claim and invited Mrs C’s solicitors to discontinue it, the claim was indeed discontinued.
In the New Zealand context, this patient may raise a complaint through the HDC. After receiving initial responses from Dr O, the HDC could decide to open an investigation. The HDC are likely to gain an expert report from a NZ based practitioner working in a similar healthcare context, if possible. Dr O would be invited to provide a further response to the provisional HDC report and Medical Protection may consider an additional expert report if necessary. The HDC does have the option of finding the practitioner in breach of the patient code of rights but when the practice is of the expected standard, can demonstrate appropriate informed choice and consent, is well documented and does not attract a critical expert report, a breach finding is unlikely.
The HDC has a memorandum of understanding with the Medical Council and will notify the Council when opening an investigation. The Council may choose to wait for the outcome of the investigation before requiring any further information, or request information about the doctor’s current practice and CPD while awaiting the outcome of the investigation.
The patient is entitled to be assisted with the completion of and ACC Treatment Injury Claim. ACC will determine if the patient has a personal injury as an outcome of treatment and if the patient is entitled to any compensation. The treatment is likely to be provided in the public system and recovery time short in this case.
• There was a factual dispute in terms of evidence but the claim was discontinued without recourse to the courts.
• While being an uncommon phenomenon, uterine perforation with an IUCD is an important risk that must be explained to patients. There is an increased risk in the postpartum period up to 18 months and when breastfeeding. Care is required to insert the device safely and diagnose and manage any potential perforation appropriately.
• Patients should be allowed time to reflect on any discussions with their clinician before determining whether to proceed.
• Most perforations occur at time of insertion, but on occasion a ‘secondary’ perforation can occur, and a partial perforation can convert to a complete perforation.
• The case reinforces the importance of good note keeping in relation to discussions, consent and follow up advice.
• Practitioners should also keep up to date with current best practice on performing procedures in the GP setting, and they should refer to colleagues with experience of carrying out a procedure as appropriate.