A 24-year-old woman with profound deafness had a congenital rectovaginal abnormality repaired. Subsequently she had had two successful pregnancies delivered by elective caesarean section. She presented in her third pregnancy and was booked for an elective caesarean at 36 weeks. An interpreter was present for the discussion.
One week before the operation consent was obtained by the SHO. The patient signed the consent form which specified that she would undergo a caesarean section.
A week later a normal child was delivered. Two days after delivery the patient became extremely agitated and with the help of an interpreter she made it clear that she had expected that a tubal ligation would also be performed at the caesarean section. Since no such procedure had been performed she was counselled about various contraceptive options.
The patient was discharged four days later. A clinic appointment was made for a routine postnatal examination in six weeks. She failed to keep this appointment and presented to the out-patient clinic nine months later. Early pregnancy was confirmed and a claim against the hospital was intimated. The patient contended that the hospital had negligently failed to perform a tubal ligation in accordance with her instructions. This, she argued, had caused her additional unplanned pregnancy and financial loss. Legal aid solicitors wrote to the hospital seeking copies of the medical records.
A review of the records indicated that the patient would almost certainly fail in proceedings. At the first antenatal visit in her third pregnancy the patient had been booked by a midwife. The midwife noted that the patient 'would like tubal ligation after this delivery'. The patient had been seen by the consultant at 36 weeks. He noted a transverse lie but was unaware of the patient's wishes regarding sterilisation. At the next appointment an interpreter was present and the proposed caesarean section was discussed in detail. No request for tubal ligation was documented.
When the patient had finally been admitted for her elective caesarean section the records clearly documented that the deaf centre had been contacted to provide an interpreter to clarify the patient's needs. Again, no mention of tubal ligation was recorded. Two days after the delivery, medical staff wrote the following:
'is upset and teary this evening as she had wanted a tubal ligation done with this caesarean section and had thought it was done. I have explained ... that she has only had a caesarean section ....'
On the following day medical staff again documented:
'Despite a long counselling session with a deaf-mute interpreter a week before the caesarean section, and multiple visits since then, there has never been any mention of tubal ligation….
Discussion with patient via interpreter. She did not realise that apart from the 'booking' visit she would need further counselling regarding tubal ligation. The options are:
- oral contraceptive
- interval tube ligation
- interval vasectomy for her husband.
Discussed with patient regarding:
- small failure rate of tubal ligation (between 1:500 and 1:200, higher level post LSCS)
- finality of tubal ligation
- small evidence of menorrhagia.
She will use norethisterone whilst breast feeding then oestrogen/progestogen after weaning. She will decide after discussion with her husband regarding later tubal ligation or vasectomy.'.
Finally, the records documented that a prescription for the oral contraceptive had been handed to the patient prior to discharge and that a six-week review appointment was made.
It is probably unnecessary to add that no proceedings followed in this case where excellent medical records prevailed.
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