12. Mrs I says the Trust refused to remove the coil when she requested it. Mrs I says she was given differing reasons as to why the coil could not be removed. She says she was told by a consultant the coil could be removed at any time but was told by a different doctor the coil could not be removed until a scan had determined the location of the pregnancy.
13. Mrs I said she asked for the coil to be removed on 8 October and was advised her GP would have to remove it as they had fitted it. She says she spoke to her GP who advised they could not remove it. She says she asked the Trust again on 9 and 10 October and was told the coil would have to be removed at a later date when the location of the pregnancy had been determined by ultrasound scan.
14. Mrs I told us as a result of staff giving her differing reasons for why they would not remove the coil, it fed into her belief staff were trying to prevent her from having a termination and were judging her for wanting a termination.
15. The Trust said when the location of a pregnancy is uncertain, a coil would not be removed until the location and viability is confirmed. The Trust said Mrs I’s coil was removed once the scan on 18 October showed a pregnancy in the uterus. The Trust told us it does not have a policy for the removal of the coil.
16. On 5 October 2023 Mrs I was admitted to hospital through the Emergency Department (ED). Mrs I presented with abdominal pain and bleeding of around 11 days. Her HCG levels were taken and shown to be 419. Mrs I tested positive for pregnancy. An ultrasound scan was taken which did not reveal a pregnancy. Mrs I was diagnosed with a pregnancy of unknown location.
17. On 6 October 2023 Mrs I’s HCG levels were 786. Staff advised as this was more than a 60% rise in HCG levels it was likely to be an intrauterine pregnancy. However, the Trust advised it was too early to rule out an ectopic pregnancy. Mrs I explained she did not want to continue with the pregnancy. The plan was for Mrs I to return for further testing of HCG levels and an ultrasound scan.
18. On 9 October 2023 Mrs I attended for an ultrasound scan. The scan showed no evidence of an intrauterine pregnancy. The Trust said a clinical plan was made to repeat a blood test the following day to determine the level of pregnancy hormone and if this increased as anticipated, then a rescan would be required in 10 days.
19. On 10 October 2023 Mrs I called the ward as she was frustrated staff had been unable to confirm the viability of the pregnancy. The staff member explained early pregnancy can be hard to diagnose and it can take time to get the right diagnosis. The plan was to repeat the scan within ten days and a scan appointment was made for 18 October 2023.
20. On 12 October 2023 Mrs I called the Trust to advise she had been for a private scan which showed the pregnancy in the uterus. A staff member advised Mrs I they could not use the private scan, and she would have to wait for an NHS scan.
21. On 18 October 2023 Mrs I was admitted for an ultrasound scan and coil removal at 10.30am. The scan showed an intrauterine pregnancy, and Mrs I was transferred to have the coil removed. At 12.20pm a senior house officer noted they could not see the coil threads and had unsuccessfully attempted to retrieve it. At 1.45pm a senior registrar was able to see the coil threads and successfully removed the coil. At 2.36pm Mrs I was given a discharge letter and a copy of the scan to show to staff at BPAS.
22. The NHS website for ectopic pregnancy says you are at increased risk of ectopic pregnancy if you are using a coil for contraception. It says it is rare to get pregnant while using a coil, but if you do you are more likely to have an ectopic pregnancy.
23. NICE guidance for pregnancy of unknown location 1.4 says ‘offer women who attend an early pregnancy assessment service a transvaginal ultrasound scan to identify the location of the pregnancy and whether there is a foetal pole and heartbeat. Be aware women with a pregnancy of unknown location could have an ectopic pregnancy until the location is determined.
24. Our gynaecologist adviser told us, if someone has a known intrauterine pregnancy the coil should be removed as soon as possible to reduce the risk of later complications. This would be true even if there is a wish to terminate the pregnancy, since removal of a coil is required prior to any type of pregnancy termination. In a situation of a pregnancy of unknown location, the guidance on coil removal is less clear, the Ectopic Pregnancy Trust states an ectopic pregnancy can be successfully managed with the coil remaining in place, although in most cases it is removed.
25. Our gynaecologist adviser told us if Mrs I was very keen for the coil to be removed, they could see no reason why it could not have been removed, even before the location of the pregnancy was confirmed. Given Mrs I’s desire for removal, the location of the pregnancy would not have made a difference.
26. Principle four of the NHS Constitution says the NHS should support individuals to promote and manage their own health. NHS services must reflect, and should be co-ordinated around and tailored to, the needs and preferences of patients. Patients, where appropriate, will be involved in and consulted on all decisions about their care and treatment. Patients play a key role in managing their own health and should be actively supported by the NHS to do so.
27. Mrs I was diagnosed with pregnancy of unknown location on 5 October 2023. The Trust carried out blood tests and ultrasound scans until a scan was able to determine the pregnancy was not ectopic. We have seen evidence the Trust followed NICE guidance for a pregnancy of unknown location.
28. In its final response the Trust said the coil would not be removed until the scan had revealed the location and viability of the pregnancy. When asked, the Trust advised it did not have a policy in relation to removal of the coil in this situation.
29. There is no guidance to specify at which point in this process the coil should be removed. Our gynaecologist adviser told us they could see no reason the coil could not be removed when Mrs I requested it, as the location of the pregnancy would not have made a difference.
30. We consider the Trust could have removed the coil before waiting for the ultrasound scan to determine the location of the pregnancy as we have seen no policy or clinical reason it could not be removed.
31. We understand this experience was distressing for Mrs I. We consider the duration of the impact to be thirteen days from 5 October 2023 when she was admitted to the ward until 18 October 2023 when the coil was removed.
32. We have carried out a precedent check and are satisfied this is not a systemic issue as we have received no other similar complaints about the Trust.
33. We consider the impact falls into level one of our severity of injustice scale which describes the impact as distress, worry or annoyance which does not impact on the affected person’s day to day functioning, or their ability to live a normal life; for a period of up to 2 weeks. In level one cases an apology is an appropriate remedy.
34. Our principles for Remedy say to put things right organisations should provide an apology, explanation, and acknowledgement of responsibility, as well as remedial action.
35. The Trust has agreed to provide an apology to Mrs I for not accommodating her preferences when there did not appear to be a clinical or policy requirement to do so. The Trust has agreed to provide a service improvement and remind its staff about point four of the NHS Constitution and the importance of tailoring care to the needs of the patient where possible.