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A notable error

01 May 2004

Mrs D was in her late forties and had been suffering from menorrhagia for six months. Her periods were not only heavy, but prolonged, and they were occurring only 17 to 21 days apart. An ultrasound scan had revealed the presence of a 3.2 cm x 3.3 cm fibroid and Mrs D was referred to Mr E, a consultant gynaecologist.

Mr E carried out a colposcopy, a hysteroscopy and a D&C. The fibroid was seen pushing into the cavity of the posterior wall and the cervix was inflamed, but no other abnormalities were detected. Mrs D had a consultation with Mr E following these investigations and evidently elected to undergo a hysterectomy.

A few days later, Mr E carried out a vaginal hysterectomy with bilateral salpingo-oopherectomy and implantation of HRT. The operation notes state that it was a ‘good procedure’, but they are short on detail. The anaesthetic record indicates that the operation took about three hours.

The vaginal pack and catheter were removed the following day and, apart from an Hb of 9.2 g/dl, for which ferrous sulphate was prescribed, nothing of note was recorded over the first 48 hours.

Two days postoperatively, however, an unexplained temperature of 38°C was recorded. The resident medical officer, Dr V, examined Mrs D, recording that she had been eating but was experiencing some nausea. Bowel sounds were present, but there was tenderness in the lower abdomen, which was soft.

He arranged for suppositories to be inserted and to re-evaluate her later. Two glycerine suppositories produced a good result and, after examining her the following day, Dr V authorised her discharge from hospital.

When she attended a postoperative check-up with Mr E three days later, Mrs D complained of pain in the right iliac fossa. Finding tenderness in the right loin, Mr E arranged for a kidney scan and referral to Mr P, a urologist.

The ultrasound scan showed hydronephrosis of the right kidney with dilation of the ureter close to the vesicoureteric junction, suggesting obstruction of the distal end of the right ureter. Mr P performed cytoscopy and unsuccessfully attempted a retrograde study.

The following day he carried out a nephrostomy and re-implanted the ureter, during which a stitch was discovered around the lower end of the ureter. Three months later, another surgeon repaired a vesicovaginal fistula. Mrs D made a satisfactory recovery, with isotope studies showing that her kidneys were functioning well and both ureters were draining normally.

Mrs D brought a claim in negligence against both Mr E and Mr P. The expert advice she based her claim on was critical of Mr E’s postoperative care, in that the ureteric obstruction should have been diagnosed before Mrs D was discharged from hospital.

According to his account, there was also evidence at this time of the vesico-vaginal fistula, which was not actually diagnosed until three months later. Apparently, Mrs D had been leaking urine, but it had been assumed that this was a leakage around the catheter and had not been investigated.

His report had no criticism of Mr P’s diagnosis and treatment of the obstructed ureter, but he felt that Mr P should have recognised the fistula when he performed a cytoscopy a few weeks later. Another expert expressed concerns about the poor quality of record-keeping associated with Mrs D’s care. In particular, there is no record of the content of the preoperative consultation.He felt that options other than a  hysterectomy should have been discussed.

We settled the claim out of court.

Learning points

Once again, poor note-keeping made it difficult to defend a case. In this case, the problem seemed to extend across the board as the nursing notes were almost as inadequate as the doctors’. The cause of abnormal signs or symptoms postoperatively should be assiduously investigated.

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