Type of publication:
*Khattak H., *Bakhai K., *Zainab O.M., *Jones C., *Swain K., *Biswas N.
BJOG: An International Journal of Obstetrics and Gynaecology, April 2015, vol./is. 122/(21)
Introduction The General Medical Council (GMC) highlights in Good Medical Practice that obtaining informed consent is one of the duties of a doctor. The GMC advocate in the consent guidelines that the process of consenting is a partnership between the doctor and patient to come to a mutually agreed decision. There may be important medico-legal implications for doctors who obtain uninformed consent. This audit investigated the documentation of this clinical interaction. In the light of this, an original audit on ‘ERPC Consent’ was carried out in 2013. The audit highlighted that ‘serious risks’ were not consistently recorded. We therefore encouraged the use of a preprinted ERPC consent form. A re-audit was carried out in 2014. Methods A total of 30 case notes and consent forms were obtained, which is 71% of total ERPCs performed over a 3-month period in 2013. These were analysed using a pro forma and results presented at a local clinical governance meeting. As a result of this meeting, the preprinted form was re-introduced. A re-audit was performed, using the same pro forma with 25 case notes (51% of all ERPCs) over a 3 month period in 2014. The results were analysed and also presented to clinical governance. Results The original audit found that in 2013 only 20% of the forms used to take consent were the ERPC specific forms. After re-auditing in 2014, the number rose to 80%. This showed significant results for improvement in documentation for serious risks, in particular infertility (from 37% to 80%), significant cervical trauma (from 10% to 52%), damage to blood vessels (from 47% to 84%) and thrombosis (from 80% to 88%). Conclusion In conclusion, the complete audit cycle showed that there is a significant improvement in documentation of serious risk factors associated with surgical management of miscarriage and provision of information leaflets to the patients about ERPC. However, we recognise that small sample size may have limited our results and therefore propose a re-audit of all ERPCs performed in 2014.