10. Our adviser explains addressing a post-birth bleed (postpartum haemorrhage) must be prompt as severe bleeding can develop quickly. They say it is important for a medical assessment and plan to happen quickly. But any vaginal examination, even in an emergency situation, is considered an intimate examination and the doctor doing it needs to be sure that they have appropriate consent from the patient. GMC professional standards on intimate examinations set out how to get consent from the patient.
11. The standards say the doctor should make clear what will happen during the examination before it begins, so the patient has a clear idea of what to expect including any pain or discomfort. The doctor should explain why examination is necessary and that the patient can ask them to stop at any time. The standards include what should also happen during the examination. The doctor should explain what they are doing before they do it and, if it differs from previous explanation, to seek the patient’s permission. It also says the doctor should be alert to the patient showing signs of discomfort or distress, and stop if the patient asks them to.
12. There is no specific guidance on pain relief during intimate examinations. Our adviser says sometimes patients can have gas and air, which can help to make an examination less painful. But is not always effective. Communicating with the patient is crucial, and if it is clear that the patient cannot tolerate the examination then the doctor should consider doing it under anaesthetic.
13. Miss L’s post-birth bleeding needed prompt attention. The Trust says a lot was going on at the time, bleeding can happen quickly and that doctors can become task focussed and can forget to communicate with the patient. But it accepts this is not an excuse. The doctor’s statement and the medical record say they got verbal consent from Miss L before doing the examination. The record says ‘examination with verbal consent’ but does not give any more details of the discussion. This and the statement do not indicate the doctor had a discussion about the intimate examination when getting consent, as detailed in the standards.
14. The records we have seen and Miss L’s account suggest there was sufficient time to talk to Miss L in more detail about what was happening. The doctor left the room for what Miss L estimates as ten minutes, to monitor her bleed before intervening, and then came back. She says she understood the examination needed to happen for bleeding but there was no consent or conversation. She says she only learned during her discussions with the complaints team that the doctor had emptied her bladder.
15. The record of the procedure says ‘clots and membranes bits removed from cavity’. The doctor’s statement confirms this was from the uterine cavity. Our adviser says this would be painful and examination of the uterine cavity is often done under anaesthetic. Miss L had just given birth so the area would likely be sore and painful. It would have been essential in this case to warn Miss L that the examination was likely to be painful. The Trust should have made her aware she could ask the doctor to stop if it was too uncomfortable. The record shows the Trust considered Miss L for further examination under anaesthetic if the bleeding continued, but as the bleeding stopped this was not needed.
16. When we weigh up the evidence, we do not think the Trust got informed consent from Miss L for the examination, or made her aware it could be painful and she could ask to stop, as it should have in line with the GMC standards. We have therefore found a failing. We next consider the impact of this.
Impact
17. Miss L says the examination caused her pain and distress at the time. She says she still experiences pain in her vagina. She says the examination was an invasion of her privacy, she feels violated and she cannot sleep at night because of how she feels about it. She also says her relationship with her partner has suffered. She has lost trust in the hospital and does not want anyone else to go through what she has.
18. Miss L needed the procedure to address her post-birth bleeding. We think even if the Trust had done the right thing and given her all the information about the examination, it is more likely than not she would have still been in some pain and discomfort at the time of the examination, particularly as she had just given birth. We understand Miss L was not expecting what happened during her examination. We think if the doctor had appropriately explained the examination and that it might be uncomfortable and/or painful, she would have been better prepared. We think that may have helped her to tolerate the pain at the time better and she could have asked the doctor to stop. On the balance of probabilities, we think Miss L would have been less shocked and confused about what was going on. Because she was not expecting this, it made an already uncomfortable experience worse for her.
19. We asked our adviser about Miss L’s ongoing pain. They said it is unlikely that this is from the examination. There is no evidence the examination caused any injury, and if it did, our adviser says it would have healed by now. Our adviser says there could be a psychological element here from the trauma of the experience. As we have explained above, we are not able to know how much of Miss L’s trauma could have been avoided, as the examination was always going to be unpleasant.
20. Miss L may have avoided some of the longer term distress this experience caused her. We understand she says she has had difficulties sleeping and with her relationship with her partner because of how she feels about the examination. She says she has spoken to her counsellor about the problems she has faced since this incident, but has declined to give us details about their discussions, which we can understand.
21. We appreciate this was a traumatic experience for her. We cannot wholly attribute the trauma from this experience to what the Trust got wrong, as Miss L would have always had the examination for her bleeding. However, the Trust denied her the chance of a better experience at an already traumatic time. She is left never knowing how much better the experience could have been for her had the Trust done the right thing.
What the Trust has done to put things right
22. The Trust investigated Miss L’s complaint and had a meeting with her. It apologised when Miss L told it there was no consent or conversation before her examination. It acknowledged the trauma this had caused her. The Trust said it believed Miss L. It said a lot was going on at the time and sometimes doctors can become task focussed and forget to communicate. But it said that was not an excuse. It said it would feed back to its staff that they should better explain a procedure and give plenty of warning. It said it had spoken to the doctor involved and contacted its reflection team, which supports staff with their professional learning, development and improvement.
23. The Trust said it believed Miss L’s account, but she felt its apology was not genuine because it gave reasons the doctor did not explain the examination to her properly. It also said the doctor had said they got her consent. the ‘NHS Complaint Standards’ say NHS organisations should be open and honest when things have gone wrong, recognise when this has had an impact on people. So the Trust had to give that explanation. It was being transparent and honest about why it felt the mistake happened. Its explanation was not intended to take away from its apology but to try and explain what happened to Miss L.
24. We are satisfied the Trust has acknowledged the mistake and the impact this has had on Miss L in line with the ‘NHS Complaint Standards’. We think there is more the Trust should do to put things right for Miss L based on the failings we have found, to recognise the impact this had on her.