A presented with a complaint of sig-nificant post-menopausal bleeding

Ms. A presented with a complaint of sig-nificant post-menopausal bleeding. Her medical history included two caesarean section deliveries, Crohn’s disease and a right hemicolectomy, cholecystectomy and hepaticojejunostomy and post-surgical pel-vic adhesions. She underwent an endome-trial biopsy, which revealed no evidence of residual hyperplasia of the endometrium. She was offered a hysterectomy to resolve the bleeding. Ms. A was appropriately advised of the routine risks associated with a hysterec-tomy, but she was not advised of the sig-nificant risk to her bowel and biliary reconstruction due to her complex medical history. Further, she was not advised about alternative treatment options including hor-monal treatment with progestogen, contin-uous HRT or a Mirena IUS. She was not advised that the bleeding would be likely to stop within around a year even if she did not undergo treatment. Unfortunately, Ms. A sustained a small bowel injury during her hysterectomy. She thereafter suffered a chain of complications including fistula and sepsis. Her condition deteriorated, she went into multi-organ failure and died at the age of 57. This case illustrates the dangers of tak-ing a “standardised” approach to the con-senting process. Ms. A needed to know that she was at significantly increased risk of serious complications if she underwent a hysterectomy, and needed to know that there were far safer options available to treat her vaginal bleeding.

Avoiding Litigation •
The consenting process does not start and finish with the consent form. Be aware that a Court will review the whole consenting process, including the records of your pre-treatment discus-sions with the patient and correspondence. • As Baroness Hale observed in Montgomery, “it is not possible to con-sider a medical procedure in isolation from its alternatives. ” Make sure that you have discussed alternative proce-dures, and the risks and benefits of these procedures, with your patient, and make a record of these discussions. • Where appropriate, advise your patient that having no treatment/conservative treatment is available as an option. • The consenting process is patient- specific and should take account of the risks, benefits and alternative treatments applicable to each individual patient. • Where your patient has a history which puts her at additional risk if she under-goes the proposed treatment, you should discuss the additional risk with the patient, quantify the additional risk where possible and make a record of the discussion. • When managing labour/delivery, pres-ent the pros and cons of different modes of delivery in an objective manner (regardless of your personal beliefs or preferences).

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Medicolegal Issues in Obstetrics and Gynaecology