Woman Joins Irwin Mitchell In Calling For Lessons To Be Learned
A woman left unable to have children naturally is calling for lessons to be learned after a hospital removed the wrong fallopian tube during surgery to treat her ectopic pregnancy.
Chelsie Thomas’ left fallopian tube was removed at Walsall Manor Hospital despite “clear and unambiguous” test results showing the potentially life-threatening condition was in her right tube, an internal investigation found.
Chelsie, 26, a clinical support worker for the hospital trust whose care she was under, was discharged the following day. She was recalled to hospital when maternity staff raised concerns after reading medical notes.
Another scan identified that she still had an ectopic pregnancy in her right fallopian tube. Chelsie, from Walsall, had to undergo surgery, performed by a different surgeon, to remove the right tube, meaning she cannot conceive naturally.
Following her ordeal, Chelsie instructed expert medical negligence lawyers at Irwin Mitchell to investigate her care under Walsall Healthcare NHS Trust, which runs the hospital.
The Hospital Trust has published an internal serious incident investigation report which came to the “inescapable conclusion” that the original procedure “was carried out without appropriate due diligence and attention.” It has classed the incident as a “never event” which is a list of problems the NHS has identified should never occur.
The NHS reports that 423 Serious Incidents classified as Never Events occurred between 1 April 2018 and 31 January 2019.
The report also found that the doctor who carried out the second procedure identified Chelsie had “an obvious” ectopic pregnancy and carried out the procedure “without apparent difficulty or delay”.
The Trust has offered to fund one round of IVF for Chelsie. It subsequently admitted liability.
Expert Opinion“Understandably Chelsie has been devastated by the events that unfolded and she is still struggling to come to terms with not only losing a child, but also the fact that she faces the possibility of not being able to have more children in the future.
“Ectopic pregnancies can be extremely dangerous and Chelsie’s care has raised a number of very worrying questions. The Trust’s own findings in its internal investigation report are quite damning.
“While nothing can make up for what Chelsie has had to go through, we recognise that the Trust has admitted liability and made several recommendations in its incident report. We urge it to ensure these recommendations are implemented as soon as possible to improve patient care for others.” Jenna Harris - Partner
Chelsie, who has a six-year-old son Riley-Jay, believed she was expecting her second child at the end of February 2018.
After experiencing bleeding she attended Walsall Manor Hospital on 7 March for a test; returning two days later for further tests when staff diagnosed she had an ectopic pregnancy.
On 12 March Chelsie underwent an ultrasound in which early pregnancy assessment unit nurses confirmed an ectopic pregnancy in her right fallopian tube.
She underwent surgery later that day and remained in hospital overnight. Following the operation the doctor who led the surgery saw Chelsie and said her right fallopian tube “had looked healthy,” the Hospital Trust’s report said.
She was discharged the following day despite complaining she remained in a lot of pain.
When preparing Chelsie’s discharge paperwork one of the nurses that performed the ultrasound raised concerns that her notes said her left tube had been removed, the investigation report said.
The doctor who removed it was “adamant” the procedure was carried out correctly, the report found. Following further discussions a more senior staff member advised that Chelsie be called back to hospital that day for further examination.
An ultrasound highlighted she still had an ectopic pregnancy. Chelsie underwent surgery the following day.
The serious incident investigation report said that the registrar and consultant involved in the first surgery seemed not to have given “appropriate weight” to the original scan result “which demanded a forensic examination of the right tube and ovary, which clearly did not take place.”
If Chelsie’s right tube had been “inspected throughout its entire length the ectopic pregnancy should have been discovered and removed,” the report stated.
Without the intervention of staff who flagged concerns about Chelsie’s care it is likely her fallopian tube would have ruptured, a potentially life-threatening condition, the Trust said.
The report also found a number of other issues including:
- Chelsie’s past medical notes were not available to the operating team before the 12 March surgery
- Her overnight post-operative care were missing elements, such as her temperature, to monitor her condition
- It was not appropriate to send her home on 13 March because of the pain she was in
- The doctor who carried out the original procedure did not perform the ultrasound themselves because of time pressures
- There was a breakdown in communication and teamwork between the registrar and consultant during surgery on 12 March
The report identified 11 areas for improvement including:
- The competency of the doctors involved in the incident should be reviewed
- A review of the Trust’s policies, including the roles of surgeons and assisting surgeon
- Availability of medical records must be improved
- A review of the availability of recording equipment in gynaecology theatres
- Discharge planning documents should become routine for every patient to ensure patients are not sent home without adequate pain relief.
Chelsie said: “None of this seems real. I am heartbroken and just feel numb at what has happened and devastated at how I can no-longer have children naturally.
“After I came round from my first operation I felt really ill. I was in so much pain which continued throughout the day.
“The next day the doctor who carried out the surgery came to see me and at this point told me that the operations went really well and I was told I go home that morning.
“Shortly after I got home I received a call asking me to go back to hospital for a scan. As I was being scanned I said that I thought that the ectopic pregnancy had been removed and then I saw my baby’s heartbeat on the screen.
“I started to cry instantly. I couldn’t speak as I was lost for words. It has been difficult to come to terms with the fact that I have not only had unnecessary surgery but have been left unable to have more children naturally.
“I had planned on having two more children as I come from a large family. I wanted Riley-Jay to grow up with little brothers and sisters.
“The hospital has classed this as a ‘never event’ and it is difficult to understand how this has happened. I just hope that it doesn’t happen to anyone else.”