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Perforation of uterus during insertion of IUCD (03HDC15569)

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(03HDC15569, 10 December 2004)

General practitioner ~ IUCD ~ Disclosure of risks ~ Treatment facilities ~ Expired medication ~ Professional standards ~ Communication ~ Rights 4(1), 4(2), 5(1), 6(1)(b)

A 38-year-old woman consulted a GP at a local medical centre for advice and counselling regarding the fitting of an intrauterine contraceptive device (IUCD). The GP was a locum who, although unfamiliar with the medical centre, had experience in fitting IUCDs. As the woman did not want to pay for a second consultation, the GP agreed to fit her IUCD in between appointments at a later date free of charge. The GP did not feel comfortable fitting the IUCD in the medical centre's treatment room because of a lack of privacy, so instead carried out the procedure in the consulting room, which was not as well equipped.

Following the procedure, the woman was given a free sample of pain relief, Syflex, and a prescription for some more, and advised to have an ultrasound scan to check the placement of the IUCD. The woman returned home in considerable pain and, over the next few days, experienced cramping pains and pain in her ribs. At her ultrasound appointment the IUCD could not be located, and a further X-ray revealed it within her abdominal cavity just below her ribs. The device was removed that day by laparoscopy at a local hospital. During the operation a fundal perforation on the right side of the uterus was found.

The GP was found in breach of the Code on several counts:

1) The GP did not give sufficient information to the woman, particularly in relation to the risk of perforation, and appeared to have emphasised the simplicity of the procedure, without properly discussing the risks or possible complications. The written information provided should have been explained, and the discussion documented more clearly in the notes. The GP was found in breach of Right 6(1)(b).
2) During the procedure the GP had used makeshift equipment, such as a torch as a light source. Her decision to use the examination room instead of the treatment room, with no assistance, created a number of problems, and her excuse that the treatment room did not provide privacy was unacceptable. In the circumstances she should not have proceeded. She also forgot to remove the speculum at the end of the procedure. She was disorganised, and did not make sufficient checks or take appropriate care, and was held to have breached Right 4(1).
3) The GP failed to establish the level of pain the patient was experiencing during the procedure, and did not explain the need to leave the room several times during the fitting. This was considered poor communication, and the GP was found in breach of Right 5(1).
4) After taking some of the medication given to her by the GP, the woman noted that it was out of date. The GP was held to have breached Right 4(1) in failing to check the expiry dates on the medication, as well as failing to arrange to see the patient after she phoned complaining of severe pain.
5) The Commissioner was concerned that the doctor had ordered an ultrasound scan, as this is not a usual course of action following an IUCD insertion. The doctor's explanation that it was "to check the position in the uterus" was inadequate, as this could have been done by manual examination. Furthermore, the doctor's offer to pay for the scan from her practice account was "inappropriate and unethical", and she was found in breach of Right 4(2).
6) The GP's record-keeping was significantly below professional standards, with several important events omitted, and some handwritten notes not entered into the computer system for several days. This was also held to be a breach of Right 4(2).

The Commissioner was satisfied that the medical centre had provided the appropriate equipment and support for the procedure to be performed safely. However, the doctor's actions fell well below the standard of care expected of a general practitioner.