Lack of notes

Medical history

A woman in her mid-thirties saw a consultant gynaecologist complaining of irregular vaginal bleeding. The consultant carried out hysteroscopy, which showed a normal uterine cavity. He also performed endometrial biopsy, which was normal. But the patient continued to suffer discomfort, and asked for something to be done.

Endometrial ablation was suggested as a means of curing the menstrual irregularity and the gynaecologist also discussed laparascopic sterilisation at the same time, as the patient said that she did not want children.

The patient was admitted for an overnight stay. The consultant performed the laparoscopy, by inserting a disposable needle through a small incision in the umbilicus, and creating a three litre pneumoperitoneum. He then inserted a trocar and cannula, removed the trocar and passed a 5mm laparoscope.

At that point, the gynaecologist realised that the cannula had punctured the bowel, and immediately performed a laparotomy, to repair the bowel. He then performed the sterilisation, and the endometrial ablation.

The patient's hospital recovery lasted five days. Legal proceedings were commenced against the member, alleging negligence, and claiming compensation for injury and loss due to the cost of additional hospital treatment. The patient's solicitor offered the opinion of an expert gynaecologist, who said he believed the needle had pierced the bowel, and that the member had failed to carry out necessary tests to check it was in the right position.

Expert opinion

The MDU sought the advice of two expert gynaecologists. They agreed that bowel damage, though rare, was a well-recognised complication of laparoscopic sterilisation. The member concerned was a consultant with many years' experience who had carried out thousands of uneventful laparoscopies.

One expert said: "...Perforation can occur, despite every attempt to prevent it happening, simply because the needle and trocar are inserted blindly into the abdominal cavity … the perforation arose simply because of bad luck not because ofsub-standard care. Laparoscopy ... will always carry the risk of injury even when undertaken in an exemplary fashion by a competent surgeon".

The experts were, however, concerned about the lack of note-taking by the member, who had neither a record of the fact that he had explained the procedures to the patient, nor her written consent. There was also no record that he had explained the complication to the patient. The nursing notes showed the explanation had been given by a staff nurse.

Outcome of claim

Because expert opinion supported the view that the perforation was not negligent, it was felt that the claim of negligence was defensible. But the lack of notes would make it difficult to substantiate the surgeon's evidence.

The claim was settled out-of-court, without admission of liability.

This page was correct at publication on 01/03/2004. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.