Appropriate gynaecological care but poor record keeping

What happened

Mrs P had a history of heavy periods. The Trust investigated to rule out any underlying problems, and a coil was fitted to help. Mrs P returned to the hospital a few days after because she was in pain. The coil was removed but Mrs P was unhappy about the process surrounding the coil. A few months later, Mrs P went on to have endometrial ablation (surgical treatment for women who have heavy periods) as the next step. Again, she experienced pain following it. She said the machine used in the procedure broke, and she was sent home with empty painkiller boxes. The Trust later identified that the procedure had burst a hole in her bladder.

There were more investigations and Mrs P then had a hysterectomy. Following the hysterectomy, Mrs P returned to hospital with further pain, and concerns about wound management. She was admitted, and later discharged.

Mrs P complained about her gynaecological care throughout this time, but explained that she believed her ongoing urinary infection stemmed from her hysterectomy. She had also complained about the lack of records from some periods of her care.

What we found

We partly upheld this complaint. There were no failings in the care and treatment provided to Mrs P. We did not find evidence of the machine breaking or Mrs P being given empty painkiller boxes. However, we found failings in the record keeping as records of visits were not available.

Putting it right

We asked the Trust to conduct a review of record keeping arrangements and produce an action plan to make sure the failings we identified did not happen again.