Medico-legal issues in women's health

Four case studies illustrate the value of good record-keeping. By MDU legal adviser Dr Karen Roberts

GPs deal with many issues relating to women’s health and this article will look at some of the problem areas where MDU members have reported complaints or claims. Examples range from procedures, such as insertion of IUDs
and contraceptive implants, to cervical screening and matters relating to pregnancy. The following are some fictional examples, based on MDU cases, of the problems that can arise.

A 42-year-old patient attended for cervical screening. The result was abnormal and a repeat smear was required. Three letters were sent, inviting her to return, after which the practice was notified of non-attendance and the GP made a note on the record saying ‘did not attend’. The GP did not check the smear result and the practice took no further steps to notify the patient.

Eight months later, the patient saw a different GP about another problem, and this GP noted that she had an abnormal test result, advised the patient of this and explained that she needed a repeat smear. The GP carried it out and following this, a referral and further treatment were necessary.

The patient made a complaint about the delay in treatment, explaining that she was not aware the result had been abnormal and that letters had been sent to her previous address, despite her having notified the practice of the change.

The practice investigated and found that the patient’s address had been noted on the paper record, but not the computerised one. Letters had been sent to the old address. The practice resolved the complaint using its in-house complaints procedure.

In another case, a 32-year-old woman saw her GP to request contraception and various options were discussed. The patient opted for an IUD and a discussion took place, the GP making a brief note that consent was obtained.
The patient attended six weeks later and the IUD was fitted with no apparent problem. However, she later had abdominal pain requiring further tests and it was found that her uterus had been perforated at insertion. She brought a claim alleging that she had not been warned of this risk and that the procedure had been carried out negligently. The claim was settled.

Incorrect procedures, delayed diagnosis
A 24-year-old woman had a contraceptive implant inserted, apparently uneventfully. Later, she asked for it to be removed. The GP failed to remove it, despite two attempts, following which the patient developed keloid scarring. The GP referred her to a gynaecologist, who removed the implant with difficulty because it was deeply sited. The patient brought a claim alleging negligent insertion and removal. The claim was settled.

A 20-year-old woman attended her GP with pain in the right iliac fossa. The GP undertook an abdominal examination and noted tenderness but no other positive or negative abdominal signs. The GP recalled that she had asked about menstrual cycle and asked the patient to submit a pregnancy test.

No note was made of the patient’s menstrual cycle or date of last period. She submitted a pregnancy test a few days later, which was positive. This was filed without action. The week after, she was admitted with abdominal pain and bleeding, and ectopic pregnancy was diagnosed, requiring emergency surgery.
The patient brought a claim alleging delay in diagnosis and that earlier diagnosis might have avoided surgery that resulted in the removal of her fallopian tube. The claim was settled.

Risk management

Some of the problems highlighted here could have been avoided by implementing simple risk management procedures.

  • Establish a system for following up test results, which includes a process for dealing with abnormal results and ensuring these are communicated to patients.
  • Consider a tracker system to log tests and patients requiring follow-up. This could be a manual or computerised log, which a nominated member of staff should check regularly.
  • Ensure your practice has a system for updating patient records.Work within the limits of your professional competence and have appropriate training, qualifications and experience for the treatment or procedures you undertake, in line with GMC advice in Good Medical Practice.
  • Make appropriate referrals for assessment and treatment.
  • Document discussion about consent in the records and note the patient has been warned of any risks and side-effects.
  • If there is a delay between obtaining consent and carrying out the procedure, review the consent and seek it again before the procedure is undertaken, as advised by the GMC.
  • If a potential diagnosis is considered, take appropriate steps to exclude that diagnosis within a reasonable timescale, depending on the seriousness of the problem.
  • Make complete, contemporaneous records.
  • If your practice has a dual record system, ensure notes made in the paper record are transferred accurately to the computer.
  • Set up an adverse incident reporting system, so the practice can analyse and learn from mistakes or near misses.
  • Explain and apologise to patients if things
  • go wrong, take steps to deal with the consequences and arrange appropriate treatment and follow-up.

The cases mentioned here are fictitious, but based on those from the MDU. Doctors with specific concerns are advised to contact their medical defence organisation for advice.

Dr Karen Roberts is a clinical risk manager at the Medical Defence Union

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