Dr Sharmala Moodley
A young student agreed to the fitting of an IUCD. Three days later she returned complaining of pain and vaginal bleeding
An 18-year-old student consulted her general practitioner to discuss contraception. In the past, she had not found it easy to take the pill regularly and felt that condoms were not sufficiently reliable. She had also tried a depot injection but found the side effects of mood changes unacceptable.
The patient and the GP discussed her contraception options and agreed that she would proceed to have an intrauterine contraceptive device (IUCD) fitted. The GP described in detail what the procedure would involve and the risks - namely an internal examination, some pain on insertion similar to a period, a small risk of infection or the coil falling out, the chance of intermittent bleeding over ensuing days/weeks and a chance that the coil might pierce or perforate the uterus. The doctor prescribed analgesia to be taken on the morning of the coil fitting and also afterwards in case of any post-procedure discomfort.
The patient attended the practice a week later for the insertion of the IUCD. The practice nurse was present as a chaperone. The doctor was careful to explain what she was doing at each stage. The patient did experience discomfort during the coil insertion, at which point the GP paused and used GTN spray to relax the cervical os. This eased the patient's pain and with her ongoing consent the procedure was completed without further problems. She agreed to come back to the surgery after her next period so that the GP could check that the thread positions were satisfactory.
However, the patient returned three days later complaining of lower abdominal pain with vaginal bleeding. Examination of the right iliac fossa indicated tenderness but there was no guarding or rebound. On vaginal examination the GP member could not identify the coil threads. She referred the patient for urgent gynaecological assessment, querying a perforation of the uterus. An ultrasound scan identified that the IUCD lay outside the uterine cavity. It was retrieved by way of laparoscopy.
One of the rare but recognised complications of IUCD insertion is perforation of the uterus, which nearly always occurs at the time of insertion
Three years later the patient submitted a claim for compensation. In their Letter of Claim, the claimant's solicitors alleged that the GP had fitted the IUCD in such a way as to cause it to lie outside the endometrial cavity and had failed to adequately assess the positioning of the device.
On the member's behalf, the MDU investigated the claim and obtained an expert opinion from a general practitioner with experience in family planning. The expert advised that the GP member's records were of a good standard and that her practice could be supported.
Our Letter of Response highlighted the GP's postgraduate training, experience as a general practitioner and as a family planning doctor. It was pointed out that the claimant's contention that perforation of the uterus following insertion of IUCD always indicates negligent treatment was untenable. One of the rare but recognised complications of IUCD insertion is perforation of the uterus, which nearly always occurs at the time of insertion. It is often a 'silent' phenomenon and clinicians cannot rely on a signal of pain from the patient to indicate that perforation has occurred. Patients often experience discomfort during uncomplicated IUCD insertions.
It was pointed out that the GP had proceeded cautiously and with the claimant's ongoing consent. The assertion that she had failed to adequately check the positioning of the device was challenged. The notes documented each step of the procedure and the claimant's solicitors failed to outline the additional steps they considered the doctor should have taken.
Some months later the claimant’s solicitors advised that they were no longer instructed to pursue a claim.
- Just because something has gone wrong, this is not prima facie evidence of negligence. Investigation may show that the doctor performed to an appropriate standard.
- Full, contemporaneous notes are essential - they can provide evidence of a good standard of care in cases where negligence is alleged.
Dr Sharmala Moodley
Deputy head of claims handling
Sharmala qualified at the College of Surgeons, Dublin and started to train as a surgeon before switching to general practice when she moved to London in 1997. She gained her MRCGP with merit in 1999 and worked as a single-handed GP before joining the MDU. She has been deputy head of claims since 2009, managing a team of 40 claims handlers while retaining a portfolio of complex high value claims.
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