Medico-Legal Issues in Obstetrics and Gynaecology Roger V. Clements 111 Harley Street

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1 Welsh Obstetric and Gynaecology Society 19 th October 2012 Medico-Legal Issues in Obstetrics and Gynaecology Roger V. Clements 111 Harley Street

2 What are the Issues? Issues that lead to litigation Issues that harm patients Are they the same? How can litigation be reduced? How can patient harm be reduced?

3 RISK OF HARM High Low Elderly Sick Illness intervention Emergency Elective Child/young adult Well Social Intervention

4 RISK OF LITIGATION High Elective Child/young adult Well Social Intervention Low Elderly Sick Illness intervention Emergency

5 WHO SUES? THERE IS POOR CORRELATION BETWEEN ADVERSE OUTCOME AND LITIGATION The Harvard Study

6 CLIN ICAL R ISK MANAGING RISKS IN GYNAECOLOGY Risk of Litigation The less the original pathology the greater the tendency for the patient to sue

7 RISK OF LITIGATION High Elective Child/young adult Well Social Intervention Low Elderly Sick Illness intervention Emergency

8 For the avoidance of litigation it is necessary to Practise within current Guidelines and to a reasonable standard

9 For the avoidance of litigation it is necessary to Practise within current Guidelines and to a reasonable standard false

10 For the avoidance of litigation it is necessary to Practise within current Guidelines and to a reasonable standard and keep good records

11 For the avoidance of litigation it is necessary to Practise within current Guidelines and to a reasonable standard and keep good records false

12 For the avoidance of litigation it is necessary to Practise within current Guidelines and to a reasonable standard and keep good records and COMMUNICATE

13 For the avoidance of litigation it is necessary to COMMUNICATE

14 What can litigation teach us? Reported cases Limited opportunity with so few trials Who keeps the records? NHS LA, but do they share the knowledge? Risk Management Adverse outcome reporting and Implementation of change? Defensive medicine

15 How Can We Reduce the Cost of Litigation? Who gets the Money? The Injured patient The Lawyers

16 How Can We Stop the Lawyers Getting the Money? Early Settlement (Owning Up)

17 What Costs Most? Trial Experts Discussions Exchange of Expert Evidence Exchange of Lay Evidence Statement of Case Pre-Action Correspondence

20 Clinical Negligence The Alternative Viewpoint Extreme honesty may be the best policy Kraman and Hamm Clinical Risk (2001)

21 What are the Issues? Issues that lead to litigation Issues that harm patients

22 What are the Issues? Gynaecology (Historically) Sterilisation Termination Screening Programmes Cervical cytology Minimal access surgery Consent Operating outwith and/or beyond consent Postoperative Haemorrhage Hysterectomy Operations for pelvic Pain

23 Gynaecology Issues Hysterectomy Hysterectomy is a relatively easy operation to perform and is often easiest when it is least necessary Sir Norman Jeffcoate Principles of Gynaecology

24 When I embark upon a hysterectomy my chief concern is to make sure I am not sued for surgical negligence

25 When I embark upon a hysterectomy my chief concern is to make sure that I achieve the best surgical result for my patient

26 When I counsel a patient concerning hysterectomy my chief concern is to make sure I am not sued for lack of proper consent

27 When I counsel a patient concerning hysterectomy my chief concern is to make sure that my patient makes the right choice of treatment for her particular circumstances

28 Communication In counseling for elective surgery the issue is one of CHOICE CONSENT is the negative aspect of the encounter, looking over our shoulder at the lawyer

29 OBSTETRIC RISK RECURRING THEMES Cascade of Events Delay Communication

30 OBSTETRIC RISK RECURRING THEMES OBPI Operative Vaginal Delivery CTGs Abuse of Oxytocin

31 OBSTETRIC RISK RECURRING THEMES OBPI Beware history Avoid traction once head arrested If McRoberts & Suprapubic pressure fail Go straight for the posterior arm

32 Maternal propulsion - how frequent? Ludicrous estimations in the American literature are derived from interrogation of hospital databases without any apparent understanding of how such databases are created.

38 Posterior Shoulder Injury Permanent injury to a posterior brachial plexus is very rare indeed.

39 Posterior Shoulder Injury (what the RCOG Guideline says) Shoulder dystocia is defined as a delivery that requires additional obstetric manoeuvres to release the fetus after the head has delivered and gentle traction has failed

40 Posterior Shoulder Injury (what the RCOG Guideline says). Shoulder dystocia occurs when either the anterior or, less commonly, the posterior fetal shoulder impacts on the maternal symphysis or sacral promontory, respectively

41 A template for reviewing strength of evidence obstetric brachial plexus injury in clinical negligence claims Propulsion injury Posterior arm injured No Shoulder Dystocia Up to date Training Appropriate protocol followed and all manoeuvres correctly performed No evidence of excess traction Correct number of birth attendants Precipitous second stage Temporary injury Iatrogenic injury Anterior arm injured Shoulder Dystocia No Recent Training Incorrect manoeuvres/persistence with an ineffective manoeuvre Evidence of excess traction Insufficient birth attendants Fundal pressure Permanent injury

ENTRY INTO SPECIALTY TRAINING USING THE CESR (CP) ROUTE DETAILS OF PREVIOUS POSTS IN OBSTETRICS & GYNAECOLOGY PRIOR TO APPOINTMENT TO NTN

ENTRY INTO SPECIALTY TRAINING USING THE CESR (CP) ROUTE DETAILS OF PREVIOUS POSTS IN OBSTETRICS & GYNAECOLOGY PRIOR TO APPOINTMENT TO NTN PERSONAL DETAILS Trainee name Surname Forename(s) NTN Details NTN