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Too late for contraception

01 May 2009

Miss C, a 25-year-old bank clerk, attended an appointment with the practice nurse, Nurse B, at her local surgery. Miss C was in a stable relationship and wished to discuss the options available to her for contraception. Miss C’s medical notes revealed that she had tried the combined oral contraceptive in the past, but had experienced side effects and was not good at remembering to take it daily. Recently she had been using barrier contraception alone.

Nurse B failed to document the contraceptive counselling provided, and only recorded in the notes that Miss C wanted to try an intrauterine contraceptive device (IUCD). No mention was made of options discussed or that Miss C had been informed of the pros and cons of any of the available forms of contraception. No note was made of Miss C’s medical history or menstrual cycle. Nurse B advised Miss C to take a pregnancy test, and the result was recorded as negative.

Miss C was given an appointment to have an IUCD fitted two weeks later, which she attended as planned. A code for “IUCD fitted” was entered into Miss C’s medical notes. No other details were recorded. It was not documented which clinician performed the IUCD fitting. No note was made regarding the patient’s last menstrual period.

Three weeks after the IUCD was fitted, Miss C began to feel nauseated and bloated. Her menstrual period had not arrived and was later than expected. She attended the family planning clinic to discuss her concerns that she may be pregnant. It was five weeks after the previous, negative pregnancy test and a pregnancy test at this latest appointment was positive.

Miss C expressed her worries that her recently-inserted IUCD may have an effect on her pregnancy. The family planning doctor arranged for an urgent pelvic ultrasound at the local Early Pregnancy Assessment unit. This revealed a viable intrauterine pregnancy of eight weeks’ gestation.

The risks and options were discussed with Miss C by the gynaecology team and they decided to attempt to remove the coil there and then. unfortunately this attempt was unsuccessful and the IUCD was left in situ. Miss C advised her GP, Dr A, that she wanted to continue with the pregnancy. She was informed of the higher risk of miscarriage associated with an IUCD in utero.

Unfortunately, Miss C miscarried at 20 weeks. The patient made a claim of clinical negligence in relation to her treatment.

Expert opinion

A GP expert reviewed Miss C’s medical notes. They were critical of Nurse B’s notekeeping in relation to the contraceptive counselling. There was no record of whether the pros and cons of an IUCD were discussed or other options given. There were no details of the patient’s menstrual cycle. The GP expert was also critical of the notes made on the day the coil was fitted.

There were no details of who fitted the coil, Miss C’s last menstrual period or the time of last unprotected sexual intercourse. The GP expert also criticised the care of Miss C in view of the fact that a pregnancy test was taken two weeks before the coil was fitted. A pregnancy test should have been taken immediately before the IUCD fitting, as well as an appropriate menstrual and sexual history. The IUCD fitting should not have proceeded on this date.

Learning points

  • The importance of taking an adequate history, particularly in relation to someone who has had difficulty with using contraception in the past. 
  • It is important to document options offered to a patient as evidence that informed choices are made. 
  • It is vital to keep good records. Good documentation reflects good practice, and it is also the basis for a good defence. 
  • Clinicians must take adequate measures to ensure that a patient is not pregnant prior to fitting an IUCD. This should include fitting the device within a few days of the first day of her period or, if not possible, obtaining a negative pregnancy test within the 48 hours before the device is fitted. 
  • Practices should ensure they are covered for vicarious liability for the actions of their staff, and ensure that nursing staff, working in their own professional capacity, have their own indemnity arrangements in place.
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