Gynaecology – lessons from litigation

Lessons to be learned from high-value gynaecology claims are examined here by Dr Sarah Townley. 

The commonest underlying causes for high-value clinical negligence claims involving independent gynaecologists over the last 12 years at Medical Protection have been:

 Inadequate surgical technique;

 Failure to involve a specialist;

 Poor postoperative care;

 Inadequate consent process; 

 Insufficient documentation.

Let’s look at claims experienced by consultant gynaecologists working in private practice in the UK we saw between 2010 and 2022, specifically excluding any obstetric care. 

Surgical technique

The commonest outcomes due to alleged poor surgical technique were bowel perforation – predominantly small bowel – nerve injury, arterial injury and bladder/ureter injury. 

Subsequent to these injuries, concerns were often raised that the injury was not identified during the operation and hence a significant delay in treatment occurred. 

In addition, the choice of operation and approach was also questioned in several claims, particularly when more conservative options were potentially available. 

 

Specialist involvement

In multiple cases, the gynaecologist was criticised for not involving a specialist during the assessment or treatment of the patient, but most commonly this involved the failure to involve a general surgeon when the patient presented with a complex surgical history pre-operatively or during the operation when complications occurred (see box below). 

Sadly, this could in some cases be due to a simple failure in communication as to when the pre-operative assessment or operation were taking place. 

Postoperative care

Criticism of postoperative care mainly arose from failure to identify the complications of surgery – commonly bleeding, bowel perforation and infection – in a timely fashion, often due to inadequate monitoring or failure to act on clinical signs – raised C-reactive protein level, hypotension, abdominal pain – leading to a delay in treatment. 

Availability of the consultant or difficulty in contacting the consultant postoperatively also featured within several claims. 

Consent

Clinicians are increasingly aware of the necessity to provide adequate detail of the risks and benefits of any procedure or treatment they are providing. 

While concerns still arose that the patient was not warned of specific risks or complications, it does appear the expectation is that the consent should be now more tailored towards the individual patient rather than just the general treatment offered. 

For example, advising the patient regarding increased risks of complication/infection due to regular intake of immunosuppressant medication. 

Often the vulnerability identified in relation to consent was the failure to advise of alternative options, the option of no treatment or offer a second opinion.

Finally, in investigative procedures, it became increasingly clear that it was required for a detailed consent procedure to include not only the risks and benefits of the original investigative procedure, but also any subsequent treatment that would be undertaken during the operation and for this to be clearly documented. 

Documentation

Not unexpectedly, documentation was often a critical factor in the decision as to whether a claim should be settled or defended, as clear documentation can clearly demonstrate what actions or discussions have or have not taken place. 

In many cases, there was often an alleged failure to document in sufficient detail the consent process – options offered, risks/benefits advised – reasons for choosing a particular procedure, the operation note or evidence of adequate postoperative review/assessment.

Simple errors in documenting test results or passing on incorrect test results to colleagues, particularly within the IVF arena, also featured within these claims. 

Dr Sarah Townley (right) is deputy medical director at Medical Protection

See ‘Anaesthetic errors under the spotlight’ 

 

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