Decision Report 201405120

Summary

Mr C, who is an advice worker, complained to the board about the care and treatment Ms A received from Stobhill Hospital in relation to the fitting of a mirena coil (a contraceptive device inserted into the womb which can treat heavy bleeding). Six years later, there were difficulties in removing the device. It was found to be embedded in her womb and had to be removed under general anaesthetic. Ms A believed that she may not have been suitable for a mirena coil because of having a retroverted (backward-tilting) womb. She felt that this should have been taken into account before the device was implanted, and was concerned about not being properly informed of the risks.

We took independent advice from one of our medical advisers who is a consultant gynaecologist. We found that there were no clear records of a verbal discussion taking place with Ms A about the possible risks associated with the procedure. However, there were clear records showing that the doctor had given her a patient advice leaflet, which provided enough information for Ms A to make an informed decision. We also found that, before fitting the coil, the doctor had carried out a pelvic examination to check the positioning of Ms A's womb. This was in accordance with national guidelines and done to ensure that the mirena coil was appropriately positioned. It can be difficult to clearly identify the positioning of a woman's womb, and although it was likely in retrospect that the womb was retroverted, we did not consider this an unreasonable failing at the time.