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Monitoring of, and provision of information about risk factors in prescribing combined oral contraceptive (11HDC00440)
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(11HDC00440, 14 November
General practitioners ~ Medical centre ~ Combined oral
contraceptive ~ Good prescribing practice ~ Information provision ~
Discussion of risk factors ~ Medical review ~ Monitoring ~
Documentation ~ Rights 4(1), 4(2), 6(1)(b)
A woman was repeatedly prescribed the combined oral
contraceptive pill (COC) Estelle, even though she presented with a
number of risk factors that should have been carefully discussed
The woman was overweight, a smoker, over 35 years of age, and
had a family history of thromboembolism. She was therefore at risk
of developing a deep vein thrombosis (DVT) and, given that risk,
Estelle was not a recommended method of contraception. However, she
also had polycystic ovary syndrome (PCOS). Estelle is indicated for
treatment of symptoms associated with PCOS. The woman had taken
Estelle in the past, but her general practitioner (GP) at the time
deemed Estelle to be unsuitable because of the woman's risk factors
for DVT, and had prescribed the minipill instead (which does not
carry the same risks as Estelle).
The woman transferred her primary care to a Medical Centre where
she saw a GP, who prescribed Estelle for the woman, but did not
document the provision of that prescription. The GP also did not
document any discussion of the risks associated with Estelle or the
alternative options for contraception or treatment of PCOS.
Over the next three and a half years, the first GP and two other
GPs at the Medical Centre provided repeat prescriptions of Estelle
for the woman. Over that time, the woman's risk factors increased.
No medical review was undertaken to determine whether Estelle was
suitable, and there is little documented evidence of a discussion
with the woman about her risk factors. The woman's blood pressure
was not recorded for two years. Each of the GPs who prescribed
Estelle for the woman assumed that the previous provider had
discussed risks of, and alternatives to, Estelle with her.
The woman underwent a cholecystectomy at the local hospital. She
developed a pulmonary embolism after surgery and, sadly, died.
It was held that the first GP breached Right 4(1) by
reinstituting Estelle for the woman without a proper reassessment
of her suitability, or recording her blood pressure. The first GP
also breached Right 6(1)(b) by failing to inform the woman of her
risk factors or suitable alternatives to Estelle. The first GP
breached Right 4(2) by failing to comply with professional
standards in respect of her documentation.
The medical centre breached Right 4(1) by failing to ensure that
the woman's ongoing use of Estelle was adequately monitored through
regular, specific medical reviews and counselling on her risk
The other two GPs' care fell below an appropriate standard, but
they did not breach the Code.