Everybody makes mistakes during medical procedures.
To err is human.
But if these errors are not discussed and included in the patient's management plan, then a small problem can quickly become a life threatening one.
A young woman we will call ‘Annie” had a dilatation and curettage at a hospital.
During the procedure, her uterus was unintentionally perforated. The surgeon was aware of this error, but the potential risks were not explained to the patient or passed on to nursing staff.
There was no mention of the surgical error in Annie's discharge plan.
No medical follow up was organised.
A week after surgery, Annie developed excruciating stomach pain and a raging fever.
She rang her friends who rushed over to see her. Concerned about her sudden deteriation they called an ambulance.
Annie was taken to the Emergency Department of the same hospital where she had been discharged after her surgical procedure only a week before.
Nurses took her temperature. It was over 40 degrees. Her blood pressure was low, her pulse thready and weak. Her abdomen was also hard and swollen.
An Emergency Doctor assessed her and ordered an urgent CT of her pelvis.
Annie was diagnosed with septic shock secondary to peritonitis. She was rushed to theatre and her abdomen opened up.
Surgeons found faecal matter that was leaking into her abdomen cavity. They tracked it back to the small nick into her bowel.
They had to physically pull her bowel out from her abdomen cavity, wash it all down, find the nick, suture it up, then replace the bowel back in her abdomen.
She was given cardiac drugs and fluids to get her blood pressure up and strong antibiotics to overcome the infection.
Annie was taken to Intensive Care and treated for shock. Two days later she was discharged to a surgical ward.
Annie subsequently spend several weeks in hospital with open abdomen drains, regular and painful dressings and continuous intravenous antibiotics.
It took her months to recover enough to go back to work.
There were no links made between the surgical error, rushed discharge and emergency readmission for peritonitis.
No apology was given to the woman for putting her life at risk, or assistance offered to help with her time off work to recover.