Photo: Supplied / LDR
A woman who suffered complications after major gynaecological surgery was not properly informed of the risks associated with her treatment, a watchdog has found.
In a recently released report, the Health and Disability Commissioner said the woman had a hysterectomy and her ovaries and fallopian tubes removed in March 2020 to manage severe pain and heavy menstrual bleeding that was causing anaemia.
Her bladder was injured during surgery, requiring further medical intervention over several months. The removal of her ovaries rendered her menopausal.
Deputy Commissioner Rose Wall found the obstetrician and gynaecologist breached the Code of Health and Disability Services Consumers' Rights by failing to inform the woman of the risk of injury to her bladder before the procedure, and for not providing adequate information to allow her to make an informed choice about the proposed treatment.
The private gynaecology clinic itself was not found to have breached the code.
At a consultation with the specialist in August 2019, the woman was found to have multiple fibroids in her uterus and adenomyosis, which were causing her serious pain and excessive bleeding.
Several options for treatment were discussed in the following months, including endometrial ablation, the insertion of a hormonal intrauterine device (IUD) and a prescription of hormone tablets.
The excessive bleeding and pain had not abated by the following February and the specialist advised that a total hysterectomy and the removal of her ovaries and fallopian tubes was required.
The specialist told the HDC that prior to any surgery, he usually discussed the procedure in detail - which in this case would include complications such as intraoperative bleeding, infection, blood transfusion, deep vein thrombosis, and possible injury to the bowel and urinary system.
The clinical record of the woman's consultation before surgery did not record any such discussion.
Before her surgery on 6 March 2020, the woman signed the private hospital's consent form for her procedure.
It stated she had been informed of the risks of the procedure and that she might require further treatment if any complications arose, but it did not document the specific risks and complications of the procedure.
After the surgery, she reported that her pain was unmanageable and after being discharged, she developed extreme pain and bloating in her abdomen.
Almost two weeks later, she presented to hospital where an injury to her bladder wall was identified and a catheter inserted. She then developed signs of sepsis and was transferred to another hospital where she received IV antibiotics for two days before being discharged again.
She went to hospital four times in the weeks that followed, due to severe pain, fluid in her abdomen and incontinence.
On 14 April 2020, the woman went to hospital again on the advice of her GP and was admitted to the urology ward, where a camera and dye test found that her bladder was not fixed and a further procedure was required. It was completed successfully almost two months later, and she was able to have the catheter removed.
The doctor told the HDC he wanted to apologise for the upset and distress the woman had experienced.
"I very much wish she had not suffered from a complication and her post-operative course had been different for her. I do hope that she has fully recovered … [her] complaint and this investigation process has been a salutary lesson for me and it has highlighted the importance of the informed consent process I undertake to ensure my patients are provided with all the relevant information to enable them to make an informed decision on their care."
He accepted his documentation could have been better and said he now ensured all discussions with patients relating to consent were recorded, including all the issues discussed, specific risks/complications for the surgery to be performed, and general complications of the surgery.
He also now recorded that patients were provided with the relevant brochure for their surgery.
In addition, the doctor said that he was considering using consent forms tailored for the procedure/surgery to be performed, which will include the specific risks for the procedure/surgery to be undertaken along with more general risks associated with surgery.
Wall also recommended the doctor review the Medical Council statement on 'Informed Consent' and provide a reflection to HDC; complete further online learning regarding informed consent; and complete an audit of his clinical documentation examining the recording of consent discussions.