Cervical cancer is the fourteenth most common cancer in women, with over 3,000 new cases per year in the UK. Screening for cervical cancer started in the 1980s and since the 1990s the rates of cervical cancer have fallen by 25%. Research has shown that cervical screening prevents 70% of cervical cancer deaths each year in the UK and if all eligible individuals regularly attended screening this would increase to 83%.
It remains to be seen what effect the pandemic will have on the impact of screening. Although the numbers invited for cervical cancer screening went up by 4% from 2018/19 to 2020/21, the numbers participating in screening went down by 12% during that period.
Women aged 25 to 49 are invited for screening every three years, and every five years after that until the age of 64.
Although many healthcare professionals consider cervical screening a routine test, it is an intimate procedure and many women find it distressing. It is therefore perhaps unsurprising that complaints can arise if patients feel they haven't been dealt with in an appropriate and sensitive manner.
We reviewed files relating to cervical cancer and smears for the five years between 2017 to 2022.
There were over 280 cases opened in this period to cover claims, advice files and assistance with other processes including complaints, GMC investigations, police and Coroner investigations.
The claims cases involved GPs, primary care nurses and doctors working in independent practice. Primary care claims relating to incidents happening on or after 1 April 2019 are covered by the Clinical Negligence Scheme for General Practice, with the MDU being notified of claims from incidents before then.
The vast majority of claims alleged delayed diagnosis of cervical cancer. The alleged delays occurred for a variety of reasons such as failure to examine, inadequate smears, failure to recall patients for a smear test, and failure to refer promptly or refer at all to specialist care.
Among the cases that related to the other medico-legal processes listed above, such as patient complaints, there were some common themes. We examine these in more detail below.
Pain and discomfort
A leading reason for patients to express dissatisfaction following a smear test was that they had experienced pain during the procedure. For several this vaginal or abdominal pain persisted after the examination and other symptoms were reported such as an infection, bleeding, vaginismus, and lacerations.
While having a smear can be uncomfortable, it seems that some of these complaints could have been avoided by managing patient expectations around the test better. This relates to the broader theme of consent.
The next most common reason for a patient complaint was that they felt inadequate information was given before and after the procedure. Patients commented that they were not told what the procedure would entail and did not know what to expect. This was the case even when patients had previously had a smear test.
They also commented that they had not been told about changes in the procedure since their last test, such as not using lubricant and not using a sheet to cover them before the procedure. Some of these comments may be explained by changes in national guidance; for example, cytology methods mean the use of lubricants is discouraged.
Withdrawal of consent
Several patients complained that the clinician carried on with the procedure after the patient asked them to stop due to pain or discomfort.
There were a surprising number of cases where, as a result of discomfort and/or lack of consent, the patient alleged that they had been assaulted during the smear test. It should be noted that chaperones were not usually present nor was there documentation in the notes about whether the patient had been offered one. This may well be because the tests were usually performed by female clinicians and therefore an assumption was made that a chaperone was unnecessary.
Attitude of clinician
Another common allegation was that of poor attitude or inappropriate comments during the smear test. Patients described clinicians as being rude, dismissive, unsympathetic or even rough during the procedure. Several patients complained that the clinician did not answer their questions or explain what they were doing during the procedure. Echoing the above point about withdrawal of consent, several patients also complained that they were dissatisfied that the clinician ignored their obvious cries of pain during the procedure and did not stop or ask if the patient was OK to continue.
There are several important issues that were highlighted by the analysis of MDU cases. Allegations were around consent, chaperones and poor attitude.
Ensuring valid consent
Consent is vital for any examination or treatment for both legal and clinical reasons. An examination without consent is an assault in law. Clinically, cooperation from the patient is necessary for most examinations or procedures. In order to be valid, consent needs to be voluntary, informed and free from coercion.
The GMC guidance, Decision making and consent emphasises the importance of knowing your individual patient and has a strong focus on dialogue with patients.
Healthcare professionals need to give patents the information they want or need to make a decision in their own particular circumstances, and that information needs to be tailored to the particular patient. Even if patients have been invited for cervical screening, the responsibility for giving information and taking consent lies with the professional undertaking the procedure. It is also important as part of informed consent to appropriately manage patient expectations, acknowledging the possibility of discomfort and what to do if that happens. This will help you to maintain trust and to avoid negative feedback.
Consent is an ongoing process rather than a one-off event, and patients have a right to give or withdraw consent at any time. If the healthcare professional continues with an examination after consent is withdrawn then they are committing an assault. Therefore, if a patient says that they want to stop the procedure, the clinician should do so and clarify the wishes of the patient.
Practitioners should take care to record what information or explanation has been given to the patient in the clinical notes.
You can find our guidance on consent here.
Intimate examinations and chaperones
The Royal College of Nursing has produced guidance on genital examination in women, which explains that a chaperone present at an examination safeguards both patient and nurse. The chaperone is a witness to continued consent to the procedure and can act as an advocate for the patient, ensuring that the patient feels safe and comfortable during the procedure. All women should be offered a chaperone for intimate examinations or procedures, even when the nurse is the same gender as the patient.
The offer of a chaperone should be documented in the notes and also whether the patient accepts or refuses the chaperone. If the patient accepts, the name of the person acting as a chaperone should also be recorded.
It's important to realise that allegations against healthcare professionals of sexual assault or inappropriate examination can be made by patients of the same gender as the healthcare professional.
Potential consequences for patient and practitioner
The consequences of not obtaining informed consent or continuing with a procedure when consent has been withdrawn can be serious for the practitioner. Consequences can range from upset patients to complaints to the practice, GMC/NMC or even the police. All of these potential consequences are obviously stressful for the practitioner concerned.
If patients have an unpleasant experience during cervical screening it may make them reluctant to engage in the screening programme. Since screening can reduce the risk of patients being diagnosed with cervical cancer by 60-80%, anything that discourages patients from engaging with the programme could have life threatening consequences.
- Give patients full information about the procedure and allow them to ask questions.
- Offer a chaperone and document the offer and the patient's decision in the records.
- Explain what you are doing before and during the procedure.
- If the patient withdraws consent, stop the procedure when it is safe to do so.
- Try to preserve the dignity of the patient.
This piece is adapted from our 2018 article in the MDU journal.
This page was correct at publication on 02/03/2023. 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.