• A doctor failed to reinsert a contraceptive device, leading to a person becoming pregnant and having a traumatic termination.
• Deputy Health and Disability Commissioner Vanessa Caldwell found the doctor in breach of the Code of Health and Disability Services Consumers’ Rights.
• The clinic apologised and implemented changes; the doctor was advised to improve communication and documentation skills.

A person with a “major fear” of falling pregnant ended up needing a termination after a doctor at a sexual health clinic failed to reimplant a contraceptive device when the other one expired.

It led to an “extremely traumatic” termination and a complaint against the doctor, who was unable to justify what happened.

In a report released today, Deputy Health and Disability Commissioner Vanessa Caldwell acknowledged the ongoing traumatic effect of the event on the non-binary complainant, Mx A.

Caldwell found that the Code of Health and Disability Services Consumers’ Rights had been breached, but commended the doctor for accepting responsibility for what happened.

However, it was clear that significant errors had been made in the provision of care, which had had “significant adverse consequence for Mx A”.

Deputy Health and Disability Commissioner Vanessa Caldwell said the doctor’s failure to replace the implant was particularly concerning. Photo / James Gilberd Photography

Mx A had a Jadelle contraceptive implant inserted into their arm in 2016, with the advice that it would need to be removed before it expired in mid-September 2021.

Mx A had told HDC that pregnancy was a “major fear”, so they took proactive steps to ensure that there were no lapses in contraception.

When Mx A did not attend a “pre-Mirena” consultation on March 31, 2021, the doctor phoned and noted Mx A did not want a Mirena (intra-uterine device) insertion but for the Janelle implant to be replaced.

An appointment was made for April, with the notes: “Implant change instead of Mirena insertion”.

Mx A attended the scheduled appointment, the pre-existing Jadelle implant was removed without any problems, and the client was feeling well afterwards, according to the clinical notes.

Mx A left the clinic under the impression that the pre-existing Jadelle implant had been removed and replaced with a new one.

However, as it transpired, the doctor had not inserted a new implant and documented that Mx A had “declined contraception”.

At the end of 2021, Mx A left New Zealand and became pregnant while overseas.

The discovery was a “huge shock”, and the termination an “extremely traumatic experience”.

When X-rays and scans did not locate an implant, the GP tending to Mx A advised them to request their clinical notes.

On review, Mx A discovered that the doctor had recorded that “contraceptive had been declined post-removal of the existing Jadelle implant”.

Mx A said that was “utterly absurd” and queried whether it had been noted as an afterthought or to cover up a mistake.

The clinic confirmed that its clinical documentation system did not allow for a clinician’s notes to be altered once written into the clinical record.

Caldwell said the doctor’s failure to replace the implant was particularly concerning given their specialised qualifications in this area and experience working at the clinic, which included “special training for implant insertions”.

The clinic’s standard operating procedures for implant removal required doctors to consider whether other contraception was required.

“In addition, I note that the clinic’s ‘toolkit’ highlighted the importance of discussing risk factors and contraception options with trans and gender-diverse consumers,” Caldwell said.

She was also critical that there was no evidence on the clinical record to show that the doctor conducted a full verbal discussion of all the information contained in the consent form before or during the appointment in April 2021.

“Dr B’s clinical records were not factually correct, namely the statement that Mx A ‘declined contraception’,” Caldwell’s report said.

Mx A also told the HDC that the lack of detailed clinical notes was “incredibly poor practice” and that the documentation did not accurately reflect what had occurred during the appointment in April 2021.

The clinic agreed that after reviewing the records, Mx A specifically requested the removal and replacement of Jadelle implants and had clearly declined the option of a Mirena IUD.

The clinic said it “could not apologise enough” for the trauma caused and had since made several changes.

The doctor was sincerely apologetic for the “adverse and unwanted outcome”.

Caldwell encouraged the doctor to continue to develop competency in effective communication, which she said was a critical component in ensuring that people of all orientations and gender identities receive acceptable and appropriate health services.

She recommended that the doctor provide a further written apology to Mx A, and attend further education and training on clinical documentation and effective communication.

It was recommended that the clinic offer to amend Mx A’s clinical record and assist with relevant applications, such as to ACC.

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.