Uterus lost after ‘routine’ procedure botched

Doctors and systems failed a woman whose uterus and parts of her digestive system were removed because of a botched ‘‘routine’’ procedure, an investigation has found.

Deputy Health and Disability Commissioner Rosewall yesterday released a report criticising the treatment the woman received from an unnamed doctor and district health board, which led to the woman suffering the ‘‘extremely unfortunate outcome’’.

The patient was referred for thermal ablation – a non-surgical procedure to remove the lining of the uterus – to help stem her heavy menstrual flow. The doctor encountered some difficulties during the procedure but did not record them. After the procedure, the woman returned to the hospital with severe contraction-like pain but the doctor believed it was an intrauterine contraceptive device (IUCD) causing the pain. She removed it and sent the woman home.

But the pain got worse and the woman eventually called an ambulance that rushed her to hospital. Emergency department staff found she had suffered a thermal injury to her uterus during the earlier thermal ablation procedure. Surgeons had to remove her uterus, fallopian tubes and part of her digestive tract.

She was also given a stoma – a small hole in the abdominal wall to which the bowel is diverted.

Wall found aspects of the services provided to the woman by the doctor were inadequate, and breached the Code of Health and Disability Services Consumers’ Rights. Wall said the doctor should have proceeded with caution when she encountered difficulties during the ablation procedure and should have documented the complications that occurred.

‘‘A woman has suffered an extremely unfortunate outcome as a result of damage during an apparently routine procedure.’’

Wall said the obstetrician/ gynaecologist should have referred the woman to the on-call gynaecology team when she saw the patient the day after the initial procedure at the hospital.

The woman should have been monitored adequately with a followup before she was discharged after her IUCD was removed.

Wall also highlighted the DHB’S lack of clear guidelines for patients from a private outpatient context being assessed at its facilities.

In response, the DHB agreed to undertake an audit of its clinicians’ private gynaecology patients who are referred or transferred to the public hospital for review. The check will ensure those patients have been referred to and admitted by the acute team in accordance with its updated policy. The doctor sent the woman a written apology.