CONSENT: RIGHT TO DECIDE


BACKGROUND: Mrs J has a long history of abdominal and pelvic pain and is referred by her GP to a private specialist. The 42-year- old is seen by a consultant gynaecologist, Mr S, who after numerous diagnostic tests discusses the possibility of performing a total hysterectomy. Mrs J agrees on the understanding that her ovaries – which she has been told appear healthy – will be conserved if possible. While performing the hysterectomy, Mr S identifies signs of endometriosis and thickening of the fallopian tubes and decides to remove both ovaries. Subsequent tests reveal the ovaries and tubes are both normal and Mrs J continues to suffer pain. She also now requires HRT for early onset menopause and this leads to depression.


Mrs J lodges a complaint against Mr S alleging clinical negligence and a failure to obtain informed consent for the removal of her ovaries. It is alleged that Mr S should


not have removed the ovaries without a more thorough assessment of their condition. It is also argued that Mrs J only consented to a hysterectomy on the basis that her ovaries would not be removed unless there was an urgent need to do so during surgery and this should have involved further discussion of the matter with her. A copy of the consent form signed by Mrs J cannot be located and only the medical note written before the operation is available for reference.


ANALYSIS/OUTCOME: MDDUS, acting on behalf of Mr S, commissions an expert report from a consultant gynaecologist. The report concludes that Mr S was not justified in removing the ovaries, particularly as the pre- operative medical note suggests Mrs J thought they would be conserved unless absolutely necessary. The member accepts that the case is indefensible and MDDUS negotiates a settlement with Mrs J.


KEY POINTS


● Always fully explain the risks and benefits for each treatment option, including potential lifestyle changes.


● Be clear about the circumstances under which you might decide to proceed to


more radical treatment when carrying out surgical procedures, i.e. to save life or avoid significant deterioration such as in cases of uncontrollable bleeding or malignancy.


● Make a clear and comprehensive note of discussions you have had with the patient


about consent before any procedure.


DIAGNOSIS AND TREATMENT: FOLIC ACID ONLY


BACKGROUND: A 32-year-old woman attends her GP – Dr H – complaining of nausea and acid indigestion. Dr H had been aware that the woman had a history of urinary tract infections and anaemia for which she had been prescribed iron tablets. He was also aware that she had two previous negative pregnancy tests.


On this occasion Dr H diagnoses reflux oesophagitis for which he prescribes Pariet – a proton pump inhibitor that acts to decrease the production of stomach acid. One week later the patient returns to the


practice complaining of severe abdominal pains and passing vaginal blood and tissue. She suspects that she may be pregnant and having a miscarriage. Dr H records in his notes: "?Early spontaneous abortion" and calculates that the patient is six weeks pregnant going by her dates. He tells her


SUMMER 2011


that at such a date the miscarriage is likely to be complete but should there be further severe pain or heavy bleeding to contact the surgery or go direct to A&E. Two days later the patient is admitted to hospital with abdominal pain and PV bleeding and it is noted that she was nine weeks pregnant. An ultrasound scan confirms a complete miscarriage and the patient is discharged after the pain and bleeding have settled. A year later Dr H receives a letter from solicitors acting for the patient claiming medical negligence. The patient alleges that Dr H had been aware of the fact that she might be pregnant and yet had still prescribed Pariet which is contraindicated in pregnancy.


ANALYSIS/OUTCOME: Dr H contacts MDDUS for assistance and strongly refutes the patient’s claim that she discussed the possibility of being pregnant. No mention is made of this in the notes and Dr H states that had pregnancy been mentioned or suspected he would routinely prescribe no drugs other than iron or folic acid.


However, with pregnancy not explicitly ruled out in the notes, it becomes a case of his word against the patient’s. A solicitor acting for MDDUS examines the file and forms the opinion that the case against Dr H is weak – not just on the disputed timing of the reported pregnancy. The key issue is causation. Guidance on the prescription of Pariet does indicate that it is contraindicated in pregnancy and breast feeding but there appears to be no data linking it with an increased risk of spontaneous abortion. Proving a connection would be difficult on the balance of probabilities. This view is communicated to the patient’s solicitors and a few months later the case is dropped.


KEY POINTS


● Consider the possibility of pregnancy in any woman of child-bearing age to ensure there are no contraindications to prescribing particular drugs.


● Record asking the question.


● Evidence must support causation in medical claims.


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