Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
The consumer complained to the Commissioner concerning the treatment she received from the provider, an obstetrician/gynaecologist. The complaint is that:
- During the consumer's hysterectomy operation at the beginning of April 1998, her left ureter was damaged in two places.
- Further to this, the complaint is that following the consumer's operation, her complaints of severe ongoing pain were not addressed appropriately by medical staff.
The complaint was received by the Commissioner on 26 June 1998. An investigation was undertaken and information obtained from:
- The Consumer
- The Provider/the Obstetrician/Gynaecologist
- The Chief Executive Officer of the Public Hospital
Medical records relating to the treatment of the consumer were obtained and reviewed. The Commissioner sought advice from an independent Obstetrician/Gynaecologist.
Information Gathered During Investigation
At the end of March 1998 the consumer was admitted to a public hospital for a hysterectomy. At the time of her admission the consumer was reported to be fit, and her consent for the operation was obtained.
The obstetrician/gynaecologist performed the operation on the day the consumer was admitted. He reported that marked adhesions were confirmed during the operation. The uterus and ovaries were freed from the adhesions. Both the ovaries and the tubes were firmly adhered to the back of the broad ligament and the uterus. The obstetrician/gynaecologist was able to free the left ovary but reported difficulties in freeing the right ovary. He therefore decided to proceed with the hysterectomy, right salpingo-oophorectomy (removal of fallopian tube and ovary) and left salpingectomy (removal of fallopian tube), conserving the left ovary.
The obstetrician/gynaecologist reported difficulties releasing the adhesions to free the uterus from the bowel and bladder, but stated that once the uterus and the left ovary were released from the adhesions the hysterectomy was completed without much difficulty.
The obstetrician/gynaecologist stated that good haemostasis (arrest of bleeding) was obtained. There was slight generalised oozing and the obstetrician/gynaecologist reported that only partial peritonealisation (covering with peritoneum) was possible in view of the division of adhesions. A haemovac drain was placed in the pelvis and rectus sheath.
The consumer was given prophylactic antibiotics and pain relief after surgery.
On the first post-operative day there was about 400ml of blood in the haemovac. Subsequently, there were increasing amounts of stained serous fluid. The drain was removed after confirming that the serous fluid was not urine, and that the kidneys appeared normal on ultrasound examination.
The obstetrician/gynaecologist stated that the consumer was passing normal amounts of clear urine and that she remained afebrile throughout the post-operative period.
Examination on the third post-operative day showed tenderness on the left side of the abdomen. An ultrasound examination showed that both kidneys were normal without evidence of hydronephrosis (distension and dilation of the kidney) or hydroureters (accumulation of urine in the tubes leading from the kidneys to the bladder). On the same day the consumer stated that she first complained of a sore stomach and swelling.
The obstetrician/gynaecologist stated that complete blood counts and repeat renal function tests on the fifth post-operative day were normal.
The consumer continued to complain of sore stomach and swelling.
A renal scan was conducted on the sixth post-operative day that showed no change from the previous examination. The kidneys appeared normal.
The consumer was discharged home on the sixth postoperative day. The consumer stated she was unhappy that she was discharged with no treatment for the collection of fluid.
Over the next few days the consumer reported she was in increasing pain.
On the ninth postoperative day the consumer began to experience diarrhoea and vomiting as well as vaginal bleeding and lower abdominal pain. She visited the obstetrician/gynaecologist who conducted, with difficulty, a vaginal examination and an ultrasound examination. The obstetrician/gynaecologist diagnosed a possible pelvic infection and the consumer was instructed to continue taking antibiotics. Blood and urine tests were also ordered.
A complete blood count showed a white cell count of 20.6 with increased neutrophils (a type of white blood cell) and high ESR. Urea, electrolytes and liver function tests were normal. MSU and high vaginal swab failed to show any growth.
The consumer was readmitted to the public hospital on the eleventh postoperative day with more pain, diarrhoea, and vomiting. At the time of admission she was assessed by a medical officer and had a temperature of 38.7, tenderness in the left iliac fossa and was mildly dehydrated.
The consumer was seen by the medical officer on the following day. She had a low BP and temperature of 39.7. She was given IV haemocel.
The obstetrician/gynaecologist was informed of the consumer's condition. He told the medical officer to commence her on IV gentamycin and continue with conservative management.
The obstetrician/gynaecologist arrived and assessed the consumer as having a pelvic infection with possible pelvic abscess. A CXR and an erect film of the abdomen were normal. The consumer was given pethedine. IV antibiotics continued to be administered and she was given two units of red blood cell transfusion.
A laparotomy was performed on that day. During this operation an abscess in the pelvis was drained. The obstetrician/gynaecologist reported no major collection of free fluid. He noted generalised inflammation and marked adhesions of the bowel and omentum to the left side of the pelvic wall, to the bladder and right side of the pelvis and these were matted together. The left ovary was deeply buried in the pelvic adhesions. The adhesions were released digitally and the ovary was freed. The obstetrician/gynaecologist then removed the ovary. He reports that the pedicle was well away from the pelvic sidewall, which was divided and doubly ligated (tied or bound with a ligature).
The pelvis was irrigated with normal saline and a haemovac drain was left in the pelvis before closing the abdomen. A naso-gastric tube was also inserted.
IV antibiotics were continued.
The obstetrician/gynaecologist reported that the consumer's temperature settled and that she was given pain relief. Her urine output was clear and there was minimal drainage in the haemovac.
The consumer dribbled urine from the urethra from four days after her second admission to the public hospital. This was treated with catheterization initially and later with ditropan tablets and she remained dry.
The consumer was discharged from the public hospital eleven days after she had been re-admitted.
The consumer was seen by a registrar at the obstetrician/gynaecologist's clinic in early May 1998 and treated for a urinary tract infection.
The consumer visited her GP on the following day and was given medication for a bladder infection. She visited an after hours medical centre two days later. Again she was given medication for a bladder infection.
The following day the consumer reported severe back pain and diarrhoea.
She was subsequently admitted to the public hospital in early May 1998. A renal ultrasound at this admission showed retro-peritoneal collection of urine and evidence of obstruction of the left kidney.
The consumer was transferred to another public hospital under the care of a urologist six days after her third admission to hospital, where she was treated for an incomplete laceration to the left distal ureter.
Independent Advice to Commissioner
The Commissioner sought advice from an independent obstetrician/gynaecologist who reported:
"The consumer suffered a significant complication following her hysterectomy. In my opinion [the obstetrician/gynaecologist] treated her appropriately, despite the delay in the diagnosis of ureteric damage.
The hysterectomy was difficult because of adhesions. This was anticipated because of the information gained at the laparoscopy performed prior to the hysterectomy. [The obstetrician/gynaecologist] states that he discussed the complication of ureteric damage prior to the surgery.
The postoperative care was also appropriate. [The consumer] was seen at regular intervals during the admission. There was concern about the amount of serous ooze from the redivac drain. There is also documentation about ongoing left-sided pain. Ultrasound examinations demonstrated normal kidneys and a pelvic collection. It was assumed that the signs and symptoms were due to a pelvic collection and she was treated with antibiotics.
The decision to perform the second laparatomy was appropriate in my opinion. On [the second] readmission to hospital [the consumer] demonstrated clinical signs consistent with a pelvic abscess and drainage of the abscess was necessary. Unfortunately the presence of inflammation and adhesions make surgery difficult and the risk of ureteric damage is higher in this situation. [The obstetrician/gynaecologist] states however that he did not suspect ureteric damage at the time of surgery.
Following the second operation, [the consumer] developed urinary incontinence. She was treated with catheterisation and ditropan and a bladder fistula was excluded by filling the bladder with blue dye and testing for leakage. Ureteric damage was not suspected at this time. In retrospect, a further renal ultrasound at this time would probably have resulted in an earlier diagnosis.
Damage to the ureter is a recognised serious complication of hysterectomy and pelvic surgery. It is more likely to occur in the presence of adhesions and inflammation. The diagnosis was considered but the three normal renal ultrasounds reassured [the obstetrician/gynaecologist.]"
The Code of Health and Disability Services Consumers' Rights
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
Right to Effective Communication
2) Every consumer has the right to an environment that enables both consumer and provider to communicate openly, honestly, and effectively.
Opinion: No Breach
In my opinion the obstetrician/gynaecologist did not breach Right 4(2) of the Code of Health and Disability Services Consumers' Rights as he provided the consumer with services of an appropriate professional standard.
While damage to the ureter is recognised as a serious complication of hysterectomy and pelvic surgery, the obstetrician/gynaecologist took reasonable actions, including an ultrasound, to ensure this had not occurred. It is unfortunate that the consumer suffered this complication, but in my opinion, the care provided by the obstetrician/gynaecologist was appropriate.
In my opinion the obstetrician/gynaecologist did not breach Right 5(2) of the Code of Health and Disability Services Consumers' Rights. The consumer stated that she persistently complained of pain to the obstetrician/gynaecologist and that the obstetrician/gynaecologist did not address her complaints.
The consumer's complaints of ongoing left-sided pain are documented in her clinical notes. I accept my advisor's advice that the obstetrician/gynaecologist took appropriate action in light of these complaints.
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