Gynaecology is a unique field, so the advice you receive needs to be equally specialised.
When you are a Medical Protection member, you benefit from more than 130 years of experience defending doctors and other healthcare professionals. That isn’t just a number – it’s more than 13 decades of specialist expertise that we use to protect you long into the future.
Medical Protection have analysed the reasons behind gynaecology cases reported to us at Medical Protection 2006-2015.
We hope you find this booklet a useful source of guidance and advice, empowering you to protect yourself throughout your career.
Gynaecology encompasses a huge range of health issues involving both surgical and medical treatments. Complications following gynaecology surgery are rare, however medicolegal cases are not uncommon due to the significant impact such complications can have on patient’s lifestyles. This analysis includes management of early pregnancy problems.
The majority of cases reported to us relate to elective surgical procedures undertaken outside of the NHS. Patients who opt for elective surgery can choose to proceed with it at any time, or not at all. Some have the alternative option of medical treatments.
Clinical negligence claims in gynaecology can sometimes lead to large financial settlements. The value of the settled claim will often include compensation for care and loss of earnings if applicable, in addition to an award for the damage that resulted from a breach of duty. Complications can result in further surgery, permanent organ damage or the loss of fertility. The value of each claim varies enormously with our highest total payment (for a gynaecology case, including claimant damages, costs and legal costs, being well in excess of £2 million.
The decision to take legal action is influenced not only by the original injury, but also by the patient’s perception of how information was provided and whether, or how, an explanation and an apology were given.
We understand you work in complex and sometimes extremely pressured environments. We know, following feedback from our members, that experiencing a complaint or claim can be concerning and a significant source of stress. At Medical Protection we want to share our knowledge, experience and expertise with you so we can provide valuable professional support.
We have analysed the support we’ve provided UK-based obstetricians and gynaecologists in almost 1,500 cases. In addition to providing advice and assistance in writing medical reports in half of these cases, we have supported our members in relation to over 750:
• Claims, as in demands for monetary compensation that embodies allegations of negligence.
• Pre-claims, which are intimations from a claimant of a possible claim for compensation.
• General Medical Council (GMC) investigations.
• Local disciplinary procedures.
We have analysed all claims including those defended, not pursued and settled. We feel sharing our learning about why patients decide to take action is valuable as well as reasons why claims are settled.
Figure 1. Gynaecology procedures leading to patients making a claim and common contributory factors
The highest number of claims related to abdominal and vaginal hysterectomies. The majority of claimants suffered damage to bowel, bladder or ureter, fistula formation, sepsis, haematoma formation, or wound dehiscence in isolation or combination. Many required further procedures such as formation of a temporary colostomy, repair of bladder, bowel, ureter or, in one rare case, nephrectomy. Where there was evidence of inadequate consent this was often due to not offering or discussing alternative options such as endometrial ablation. Our highest hysterectomy total case payment was in excess of £2 million.
The second highest number of claims related to laparoscopic surgery. The majority of claimants suffered damage either to a ureter, bowel or a major blood vessel. In half of claims that were settled there was evidence of injury to the bowel requiring further surgery such as an ileostomy. A few patients had chronic pain and had further surgery to divide adhesions. Cases were settled because there was inadequate supervision or documentation of postoperative care, for example monitoring of observations postsurgery or failure to manage deterioration in a patient’s condition in a timely and appropriate way. Our highest laparoscopic surgery total case payment was in excess of £350,000.
READ A RELATED CASE REPORT
Termination of pregnancy
The third most frequent claim was following termination of pregnancy. The most common cause was a failed procedure requiring further surgery to remove retained tissue, passing a foetus at a later date, or a live birth. A third of claims alleged negligent surgery that led to damage to the uterus or bowel and required further surgery, which in some cases was an emergency hysterectomy. There were some cases of missed ectopic pregnancy when undertaking a surgical termination of an intrauterine pregnancy. Our highest total case payment was in excess of £650,000.
Prolapse and incontinence surgery
The fourth most frequent claim was following prolapse or incontinence surgery procedures. Claimants suffered from pain, sexual dysfunction, incontinence, constipation or psychological problems following surgery. Some had damage to the bladder or ureter, which happened at the time of the surgery, or developed a fistula. Some required secondary corrective surgery. A third of the cases involved implantation of synthetic mesh or transvaginal tape. Mesh can erode through the vaginal wall, causing pain and irritation. In serious cases the mesh can erode internal organs, such as the bladder or bowel. Issues around consent were not advising of the risk of ongoing symptoms, worsening of urinary symptoms such as an overactive bladder, failure to improve or recurrence of prolapse. Our highest total case payment following prolapse or incontinence surgery was in excess of £680,000.
Surgery related to ovaries
There were some claims following surgery relating to the ovaries. There were a few cases of removing ovaries without consent or an ovary from the wrong side. Other claims were following incomplete removal of an ovary, complications of surgery such as bowel damage or bleeding requiring further procedures. There were allegations of aspirating an ovarian cyst and not removing the ovary at the time requiring further surgery. Our highest total case payment following surgery relating to the ovaries was in excess of £65,000.
The common theme running through claims in relation to labial surgery was chronic pain and discomfort. Many of these had experienced a postoperative infection. In a third of cases there was evidence of inadequate consent. Our highest total case payment following labial surgery was in excess of £135,000.
Retained foreign bodies
Despite this being classified as a Never Event across the NHS we continue to see claims arising from retained swabs or instruments.
READ A RELATED CASE REPORT
Patient complaints - common themes
We have analysed the complaints where we’ve supported obstetricians and gynaecologists. These were quite varied and sometimes related to multiple concerns. We have included complaints relating to early pregnancy but not around antenatal or intrapartum care. Most of the complaints were from patients, but some were from other healthcare professionals. The common themes were:
Poor communication, manner and attitude during a consultation, such as being unhappy with their doctor or colleague’s manner and attitude, rudeness during the consultation and inappropriate comments.
Improper intimate examinations, including inadequate consent, inappropriate comments or touching, painful examinations or the lack of a chaperone.
Inadequate discussion of risks and treatment options prior to elective gynaecology surgery or assisted reproduction procedures.
Failures and delays to diagnose, including alleged missed ectopic pregnancies, delay in diagnosis of ovarian, endometrial cervical or vulval cancer and alleged failure to diagnose endometriosis.
Regulatory and disciplinary cases - common themes
Regulatory and disciplinary cases can come from patients, senior and junior colleagues, and can be related to clinical and non-clinical issues. Key themes from the Medical Protection caseload were:
- Performance concerns, such as operative skills, clinical judgement and poor communication, for example poor manner and attitude during a consultation.
- Probity issues, for example private practice in NHS time, allegedly exaggerated training experiences, and alteration of medical records.
- Inappropriate personal behaviour, conduct or boundaries, and poor communication with colleagues.
- Inappropriate delegation or supervision.
- Member health issues.
- Alleged breach of contract or incorrect billing.
- failures or delays, for example in diagnosing gynaecological malignancy, in managing foetal distress leading to an intrapartum death, in treating sepsis, or in providing appropriate fertility investigations.
- Never Events, for example a retained swab.
Inquests - common themes
Medical Protection has assisted members in writing statements and attending coroner’s inquests. An inquest is a fact-finding exercise that is conducted by the coroner and, in some cases, in front of a jury. The purpose of an inquest is to find out who died – when, where, how and in what circumstances. Our online factsheet about inquests gives further information about what happens at an inquest.
Our analysis identified the following themes:
- Death of a baby during or shortly after pregnancy or delivery
- Complications of gynaecology surgery resulting in a death, for example bowel perforation, peritonitis, injury to major blood vessels or sepsis.
- Death of a mother during or soon after pregnancy, for example after caesarean section, following termination of pregnancy, sepsis or suicide.
Top Tips to Minimise Risk
Please note this is not an exhaustive list of recommendations but key learning points from our analysis:
- Ensure your surgical technique is regularly updated and in line with current best practice such that it would be supported by your peers
- Remember that accurate and clear documentation, which often may need to be relied upon years after the event, are the cornerstone of any medicolegal defence.
- Treat every patient with compassion, dignity and respect, including the last one at the end of a busy clinic or shift.
- Ensure close monitoring takes place after surgery and any deterioration is managed in a timely and appropriate fashion.
- When things go wrong the vast majority of patients just want two things: an explanation and an apology.
- Be open and honest with patients and their families; welcoming and listening to feedback and addressing concerns promptly and in a spirit of co-operation.
- When providing an apology deliver it with sensitivity and recognition of the distress the patient has experienced.
- Assure patients and their families that the cause of an adverse outcome will be investigated and efforts made to reduce the chance of it happening again.
- Before any intimate examinations check that your patient understands what the examination will involve, the reason for undertaking it and the purpose of having a chaperone.
- It is important to remember that what can be classed as an intimate examination may depend on the individual patient.
- Listen to what your patient would consider to be a successful outcome. Understand your patient’s concerns and expectations.
- Discuss the possible benefits and risks of all potential treatment options. Consider what is most important to that individual, taking into account their current employment.
- Explain frequent and serious complications and the implications for the individual patient if these occurred. Explain what you would do to correct complications or failure to meet their expectations. Document these discussions.
- Explain and document what the procedure will involve, the likely results and when you will see the patient afterwards.
- Your patients should be given clear information about all the costs involved and what their rights are to refunds and return of deposits if they change their mind after they have paid some or all of the costs.
- Never pressurise or rush patients into giving consent to have surgery.
Double-check that the information has been understood and decisions are correctly informed and documented.
- For elective operations always leave sufficient time,at least a week, after the consultation before scheduling the procedure to allow patients time to think things through, talk to their family or access more information.
- Perform presurgical, verbal ‘time-out’ checks against medical records of patient identity, the side to be operated on if appropriate, the proposed procedure, drug allergies and consent.
- Ensure you are fully indemnified to carry
As of 10 July 2018, NHS England has restricted the use of mesh
for stress urinary incontinence and pelvic organ prolapse surgery. Further guidance, including the stance of Scotland, Northern Ireland and Ireland, is available. Read the update on the use of vaginal mesh at rcog.org.uk
Support for your professional development
Face-to-face and virtual workshops from Medical Protection:
- Mastering Adverse Outcomes
- Mastering Your Risk
- Achieving Safer and Reliable Practice
- Mastering Consent and Shared Decision Making.
- Navigating Adverse Outcomes
- Reducing Medicolegal Risk
- Consent and Shared Decision Making.
Complete a range of e-learning modules, including communicating risk, preventing complaints and communication after an adverse even. All included as a benefit of membership at no extra cost.
Access online learning at medicalprotection.org/cpd
Advice and factcheets
Get more advice about the topics in this collection with our online factsheets and booklets. The resources also cover other topics crucial to your practice, and are available whenever you need them at medicalprotection.org