15. We first looked at Mrs Y’s concerns that the aneurism was the result of a ‘nic’ in her iliac artery. Any damage to a major artery would usually cause acute bleeding. Mrs Y signed a consent form for embolization of the right superior gluteal artery, the largest and final branch of the internal iliac artery. Our adviser said there is no evidence the aneurysm was caused by a ‘nic’ in Mrs Y’s iliac artery. Similarly, there is no evidence a hysterectomy would be responsible for the aneurysm. The superior gluteal artery is far away from any area exposed in a hysterectomy.
16. Photographs taken during the procedure show the surgeon did not operate near the superior gluteal artery and there is no evidence of vascular damage. In a standard hysterectomy, such as this one, the surgeon does not enter the space where the superior gluteal artery is.
17. Our adviser said the instrument used by the surgeon in this procedure was a Liga Sure device. This is an instrument which initially seals tissue using heat and then divides the tissue between the jaws of the instrument with a blade which moves along the middle of the instrument’s jaws in a groove. It is unable to pass beyond the end of the instrument as there is no path for it. Therefore, it is extremely unlikely this instrument could cause a ‘nic’ during surgery, leading to a pseudo aneurysm.
18. There is no guidance and there are no fixed rules to any surgical procedure. Gynaecologists are trained in basic surgical procedures and specialise to learn more advanced techniques in the later stages of training. These specialist training modules are strictly supervised, and competence is certified when training is completed. Surgeons are trained on different techniques during their training and their surgical technique will be a collection of all the techniques they have learned during their training. This relates to Intercollegiate Surgical Curriculum Programme and Royal College of Obstetricians and Gynaecologists, which says:
· ‘Demonstrate an understanding of the issues surrounding informed consent, including knowledge of complication rates, risks, and likely success rates of different gynaecological operations, together with an understanding of diagnostic methods and treatment of complications
· Demonstrate your familiarity with surgery by discussing the common operations together with common surgical instruments and sutures
· Demonstrate detailed knowledge of the basic surgical procedures in O&G, including diagnostic laparoscopy, hysteroscopy, gynaecological laparotomy for ovarian cysts, ectopic pregnancy, hysterectomy, and vaginal surgery for prolapse, incontinence and vaginal hysterectomy
· Know the principles and procedures involved in more complex gynaecological surgery for cancer and endometriosis
· Have good knowledge of the principles of safe surgery, surgical instruments and sutures and the management of common complications of surgery
· Be aware of the principles of surgical teamworking, risk management and risk reduction’.
19. We have not seen evidence of any damage to the iliac artery or the superior gluteal artery during Mrs Y’s hysterectomy. Therefore, we have not seen that anything went wrong during the hysterectomy.
20. We next looked at Mrs Y’s concerns the Trust did not undertake a scan of her right side when she had complained to the consultant of pain on that side.
21. In March, Mrs Y had a postoperative check, she had some difficulties with her bowels and felt bloated. She was prescribed steroid cream for vulval irritation. She did not complain of any other symptoms.
22. In June, a consultant reviewed Mrs Y in a virtual clinic. This review appointment had been arranged to reassess her vulval symptoms. At the consultation, she complained of a recent onset of pain in the right side of her abdomen radiating to the right loin, and blood in her urine. A recent urine test was negative. The consultant arranged for her to have an ultrasound scan to assess her urinary tract to ensure there were no issues which may be related to her hysterectomy. The Trust completed the scan at the end of June and the results were normal.
23. Our adviser said this was appropriate because, based on her symptoms, there would have been a concern about damage to the ureter, which is a recognised complication of hysterectomy. The ultrasound scan was normal other than a slight duplication of the drainage system in the left kidney, which is a birth defect and not related to her surgery. The Trust did not request any further investigations, and our adviser explained this was appropriate based on the information it had at the time.
24. In July Mrs Y complained of lower abdominal pain and rectal bleeding. She had a CT scan which showed a mass in the pelvic right wall, and Mrs Y received appropriate treatment. The adviser said the Trust would not have considered Mrs Y’s symptoms as a complication of the hysterectomy and would not have investigated this further. The recognition of symptoms and all possible and appropriate tests were undertaken. This is in line with GMC Domain 1: Knowledge skills and performance, which says, You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must:
· ‘adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient
· promptly provide or arrange suitable advice, investigations, or treatment where necessary
· refer a patient to another practitioner when this serves the patient’s needs’.
25. As the Trust has acted in line with relevant guidance, we have seen no indication the Trust did anything wrong here.
26. We understand Mrs Y’s distress, and it is clear she is concerned about her care. We do not wish to diminish the impact she says events had on her. We have seen no indications the Trust did anything wrong and will be taking no further action on her complaint. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reason for this.