A junior doctor failed to check whether a mother of a young baby was pregnant before inserting a contraceptive implant. PHOTO/GETTY IMAGES
The mother of a 3-month-old baby had no plans for more children any time soon when she went to her GP to have a contraceptive device inserted.
The Health and Disability Commissioner (HDC) has found the doctor, who was a first-year registrar and still in training, should have known to check whether the woman was pregnant before doing the procedure, but didn’t.
Three months after the appointment, the mother felt movement in her abdomen, took a pregnancy test, and found out she was 20 weeks pregnant.
The mother told the HDC the pregnancy had a “significant impact” on her as she did not feel able to cope with another young baby so soon, and the pregnancy was too advanced for a termination to be considered.
She was also concerned about the possible effects the implanted contraceptive had on the baby during the pregnancy. Once she realised she was pregnant, the device was removed.
The HDC was concerned with whether the consent process and assessment of possible pregnancy were carried out and documented adequately before the Jadelle contraceptive device was inserted.
The first thing the HDC noted was the “insufficient information” about whether the “lactational amenorrhoea method [LAM]” of contraception was being used by the mother.
This is a period of temporary infertility that comes with breastfeeding when monthly periods have not yet resumed. Risk of pregnancy is 2%, provided the baby is under 6 months of age and the mother is exclusively breastfeeding and has not menstruated since delivery.
A senior GP had been contacted by the mother about getting the contraceptive implant. The mother already had two children and didn’t want another at that time.
The senior GP knew the “urgency for reliable contraception” and arranged for the mother to see a junior doctor at the practice who had more availability to do the procedure.
The GP told HDC that she had “supervised [the junior doctor] inserting a Jadelle and was comfortable that she was competent in the procedure and the associated sexual health consultation, including the assessment of contraceptive needs”.
The senior GP also instructed the practice nurse to call the mother to find out if she was exclusively breastfeeding and, if she wasn’t, to offer condoms.
That consult happened, and condoms were offered, but there was no detail as to why they were offered, nor why they were declined by the mother.
Deputy commissioner Rose Wall said there was no detail in the nurse’s clinical notes to show “the discussion and rationale” for the offer of condoms.
“But if the practice nurse followed [the GP’s] instructions, and I have no reason to assume that the instructions were not followed, condoms would have been offered if she was not using LAM as a method of contraception.
“In any event, in my view there was insufficient information documented in the clinical record about whether or not the LAM method was being used.”
Given this, Wall said, the junior doctor who did the implant needed to get the information from the mother directly to assess whether a pregnancy test was required.
There was no information on whether the possibility of pregnancy was discussed before the doctor put the contraceptive device in place.
“[The doctor] does not recall the consultation but told HDC that her usual practice involved reliably excluding pregnancy by urine test or FSRH criteria. However, there is no documentation to support that pregnancy risk was discussed, or a pregnancy test completed, or that the FSRH criteria were used. In addition, the consent form, which states ‘my GP has done a pregnancy test today’, was generated but not signed.”
Wall said that on balance, she considered it was more likely than not that the doctor did not discuss the risk of pregnancy with [the mother], provide advice on post-insertion contraception, or exclude pregnancy.
The junior doctor told the HDC she may have assumed that a consultation had occurred with the referring GP, and that “pregnancy had been excluded based on the advice to use contraception”.
However, Wall said she considered the assessment of clinical advisers who said caution was needed when making assumptions regarding important clinical facts, and these should be reclarified.
“In my view, it was [the doctor’s] responsibility to clarify important clinical information prior to proceeding with the Jadelle insertion. I am critical of [her] failure to reliably establish the method of contraception being used by [the mother] and to test for pregnancy prior to the insertion of the Jadelle.”
Wall took into account that the doctor was a first-year registrar still undergoing training as a GP.
“Although [she] was a junior doctor at the time of the events, she had prior experience with the process of Jadelle insertion and had been assessed as competent to manage the consultation independently, including all steps associated with the insertion of the Jadelle, which included the consent process and pregnancy testing.”
For this reason, Wall held her accountable for the shortcomings in her clinical practice on this occasion.
In failing to establish clearly whether the mother was pregnant, and offer a pregnancy test, she failed to provide services to [the mother] with reasonable care and skill and breached Right 4(1) of the Code.
Wall also criticised the lack of a completed consent form and the fact that, while one had been generated, it hadn’t been signed by the junior doctor or the mother.
“The consent form contains the phrase ‘My GP has done a pregnancy test today’ and ‘I have been give[n] a pregnancy test to check at home in one month’. If the consent form had been discussed and completed correctly, these phrases would have led to further inquiry and either a pregnancy test being completed, or the consent form being adjusted prior to signing.”
Wall said that although clinical documentation records that consent was established and side effects discussed, the consent form, containing information on pregnancy testing, was unsigned.
She accepted that there was consent given for the surgical procedure, but as a pregnancy test wasn’t completed and the consent form unsigned, there was no evidence the sexual health component of the consultation was completed.
“I am unable to determine whether the failure to complete the consent process and upload the document to [the mother’s] file was a one-off incident or indicative of a systems issue. I have therefore made a recommendation designed to assess whether further action is required.”
The junior doctor has expressed sincere apologies to the mother for her unplanned pregnancy and has now developed a template to ensure the risk of pregnancy is “reliably assessed and documented” before every Jadelle insertion.
There is also a prompt to ensure the consent form has been signed by both parties. The medical centre also apologised to the mother and has updated its consent form.
The HDC had earlier recommended the medical centre do an audit of its past 10 Jadelle procedures and provide the results to the HDC. This showed that in all cases the consent form had been signed and a pregnancy test completed.
It was recommended the junior doctor also do an audit of her past three Jadelle insertions to ensure there are “no omissions in documentation”.
Hannah Bartlett is a Tauranga-based Open Justice reporter at NZME. She previously covered court and local government for the Nelson Mail and before that was a radio reporter at Newstalk ZB.
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