Alleged failure to diagnose perforated uterus

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 at 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, and 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. 

Allegations

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?

Mrs C’s solicitors obtained an expert GP report, which was critical of Dr O’s treatment. This report was shared with us and supported the allegations that had already been made. We met with Dr O and obtained our own expert evidence, which was supportive of her treatment.

A letter was sent to Mrs C’s solicitors on the basis of 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.

Outcome

After issuing our letter of response, which refuted the claim and invited Mrs C’s solicitors to discontinue it, the claim was indeed discontinued.

Learning points 

• 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, with all steps taken 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 claim 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.