Disclosure of harm

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Disclosure of harm

• Surgical case

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Mrs. P. 39 year old woman

• Regular menorrhagia
• Time off work, tired
• Left oopherectomy
• G3 P2
• Tubal ligation
• Hypertension

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GP Consultation

• Anaemic
• Bulky uterus
• Oral iron supplementation
• Tranexamic acid
• Pelvic USS
• Multiple fibroid uterus
• Referral to gynaecology

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Gynaecology Registrar

• Discussed her options for management
• Mirena IUCD
• 4 month review
• Hysterectomy (LAVH)
• Possible complications discussed
• Oopherectomy
• Haemorrhage
• Damage to neighbouring structures
• Laparotomy

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Preadmission clinic

• Seen by the Gynaecologist Dr. S
• Discussed route of surgery again ?LAVH
• Asked if there were further questions
• Consent signed

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After surgery

• Dr S explained operation
• Successful laparoscopic procedure
• Little more bleeding than average
• Expect discharge the following day
• GP follow-up

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Day 3 post surgery

• Readmitted
• Fever, right loin pain and tenderness
• Suspected UTI
• No improvement over next 4 days

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Suspected ureteric pathology

• Intravenous urogram organised
• Right hydronephrosis
• Urology referral

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Care transferred to Urologist

• Nephrostomy
• Re-implantation of right ureter
• Recovered well from surgery
• Normal renal function

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GP review

• Returned to normal duties
• Tired, headaches, difficulty sleeping, hot
  flushes
• Review of operation note right oopherectomy
• Menopausal

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Issues

• No doctor patient relationship
• Poor explanation following the surgery
• No explanation/ apology by Dr S
• Complaint

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Disclosure of harm

• Surgical case