Mrs L, a teacher, was first prescribed the oral contraceptive pill microgynon by her GP, Dr G, when she was 17. Her blood pressure was taken and recorded as normal. At this time, no other mention was made in the records of her risk profile or family history. Later, Mrs L’s medical records showed that she was changed to ovran and then ovranette, but there was no explanation why these changes were made. Mrs L was changed again to ovulen 50. The reasoning this time was due to “excessive bleeding on ovranette”. At her review consultation, Mrs L’s blood pressure was taken and recorded as normal.
When she was 26, Mrs L was seen by her GP for antenatal care, where it was recorded that she now smoked 15 cigarettes a day. Her blood pressure was recorded as normal. After her first child had been born, Mrs L was prescribed minulet, before she changed to the combined pill.
Three years later, Mrs L consulted her GP as she was under significant stress. Her records showed that she had increased her smoking to 25 cigarettes per day and did not exercise. Counselling was arranged, amitriptyline 50mg was prescribed and exercise was advised. In addition, a prescription microgynon was also issued.
For the next six years, Mrs L was given repeat prescriptions of the microgynon without any record of her blood pressure being taken or her risk factors being assessed. Mrs L was now 35, but the medical records from Dr G did not say whether she was still smoking, under a lot of stress, or whether or not she was still exercising.
Four months after her last repeat script, aged 35, Mrs L presented to the same practice with central chest pain and saw another GP, Dr F. She had been under a lot of stress for a few months. A full examination was largely normal, and a comprehensive history was taken, where it was noted that she was now smoking 30 cigarettes a day. For the first time, it was recorded that her father had had an MI aged 56. Tenderness in the costocondral area and the presence of anxiety led Dr F to prescribe paroxetine 20mgs daily and a sleeping tablet for two weeks. However, Dr F noted that Mrs L was advised to call the emergency services if the pain became worse.
Two years later, Mrs L fell to the floor with severe central chest pain and attended her GP surgery the next day. Mrs L had been getting palpitations once every two weeks that lasted two hours to two days over the previous two years. These were accompanied by sharp central chest pains.
Mrs L was noted to be under less stress now and was smoking slightly less at 20 per day. She was advised about smoking. Mrs L was referred to the chest clinic, where she was diagnosed with non-cardiac chest pain. Mrs L was seen on a number of occasions in the practice for a repeat prescription for microgynon and other matters, including further chest pain, collapse and migraine.
Aged 41, Mrs L collapsed and was admitted to the Emergency Department, where investigations found that she had had a stroke. She was unable to return to work due to paralysis affecting her left side.
Mrs L made a claim against Dr F. She alleged that he had been negligent in continuing to prescribe microgynon after she was 35 years old when she had three risk factors: a family history of heart attack, smoking and being over the age of 35.
Expert opinion
Expert opinion found that a reasonably competent GP would have stopped prescribing microgynon from the age of 35 onwards and changed Mrs L to a progesterone-only pill (or at least have warned Mrs L of the increased risks in order that she could have considered the alternative options). Mrs L’s notes show that the practice knew of Mrs L’s family history and her smoking, but despite these risks continued to prescribe the pill.
The case was settled for a substantial sum.
Learning points
- Dr F should have considered all the risk factors involved in prescribing the contraceptive pill to Mrs L. He should also have revisited the prescription as the patient reached 35 and discussions about alternatives should have taken place. For more information on prescribing the combined pill see: Faculty of Sexual and Reproductive Healthcare Clinical Guidance, Combined Hormonal Contraception (August 2012).
- Remember to exercise clinical judgment when prescribing – be careful not to just accept a patient’s request for a repeat prescription if it is not in their best interests.
- Consider what drugs are on your practice’s repeat prescriptions – careful monitoring is important, as is having a robust repeat prescribing protocol.
- Clinical notes should show the reasoning behind your decisions, as well as the clinical facts. The records here did not indicate any further history had been taken.