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Copy of labour notes says I had a clitoral tear, but no one told me at the time

(15 Posts)
cardamomginger Wed 20-Jul-11 22:28:06

That's it really. And I am very annoyed about it. I gave birth almost 10 months ago and have serious birth injuries, some of which were missed, and am heading for extensive reconstructive surgery in a couple of months. I requested a copy of my labour notes because I am thinking of making a formal complaint and the notes say that I had a clitoral tear. And no one mentioned this at the time. In the general scheme of things, and in comparison with everything else that has happened to me, a clitoral tear is minimal beyond belief. But the fact that I had one and no one thought to tell me is making me really angry angry. Just needed a rant really.

ramade Thu 21-Jul-11 13:54:14

Same with me, had a 3rd degree tear, didn't tell me how bad it was.

cardamomginger Thu 21-Jul-11 14:06:03

You poor thing sad. Terrible not to have told you - if something went wrong afterwards you'd need to know the details to tell your GP/gynae. Hope you are OK now? Having read through my notes more completely there are many things they have written that are plain wrong or misleading. E.g. that I slept well on the PN ward. Er no - not a wink. That I ate well - er no. And that I was given a bed bath in the labour ward. Er yes - but it was my doula who had to do it. The general incompetence of the hospital makes me angry about these things, which I guess are not that significant overall. But surely note-taking should be accurate and if injuries are sustained, the patient should be told about all of them. I don't see that this is asking too much.

ramade Thu 21-Jul-11 14:51:37

I only found out the shambles of my notes, when I fell pregnant with my DS 2 years later. We moved had to a different town, wasn't aware there was anything 'wrong' untill the midwife said some of my notes were mysteriously missing. She refered me to the hospital where they told me I would never have a vaginal birth again (because risk of life long incontinence). I left with my jaw to the floor, wondering why nobody told me how bad the tear was.

I too was angry for a long time.

gailforce1 Thu 21-Jul-11 15:50:28

My understanding is that your notes would be considered a legal document should any proceedings be taken against the hospital or an individual HCP. They should be 100% accurate and if you have found misleading statements then this is very serious. On the surface it may seem insignificant that it had been noted that you had slept well but it might have been something far more serious and shows that the staff were either lazy or incompetent.
I doubt that you will have the energy to bring this to anyones attention but the fact that this member of staff could not be bothered/ or was unwilling to put the truth on your notes may well end up being a serious problem for another patient.

cardamomginger Thu 21-Jul-11 17:15:30

I'll be putting together a letter of formal complaint. The main focus will be my completely ripped in half pelvic floor that they somehow missed and so didn't stitch.

Nell799 Fri 22-Jul-11 14:26:07

When do you get to see your hospital notes?

AngryGnome Fri 22-Jul-11 16:56:55

This is an interesting thread. OP I'm so sorry to hear about your birth experience, and I hope that your surgery is successful. You should complain, it is unacceptable that you were not fully informed about your own condition.

With regards to errors in notes, the midwife present during my c-section wrote in my notes that I had an episiotomy. I knew I hadn't had one (something tells me I would have noticed hmm). Anyway, this meant that on the ward afterwards, THREE midwives at different times insisted on examining me to check my (non-existent) episiotomy. When I told each of them that I hadn't had one, I was dismissed with a patronising "oh, bless you, you just don't understand" attitude. DS is now nearly 8 months, I haven't made a complaint yet as I have been focussing on healing after some pretty bad birth injuries which have left me with permanent nerve damage (as yet I am not sure if these injuries were a result of incompetence, or "just one of those things"). I find I am getting angrier and angrier about it all as time goes by, and I think I will be making a complaint soon (although I am not sure what it will achieve, other than making me feel better).

cardamomginger Fri 22-Jul-11 17:19:42

Nell - I got a copy from the Access to Patient Records department at the hospital. Was put in touch with them by PALS. There's usually a charge, but no one's invoiced me yet and I'm keeping quiet about that! I was told I couldn't have a birth reflections meeting, or whatever it is it's called, as I had left it "too late", so wasn't able to have a butchers at the notes that way.
Angry - so sorry you've had an awful time of it. I've also got nerve damage. We're hoping it will get better with time. When I had a hemithyroidectomy, my neck was numb for AGES and AGES and gradually over the years the sensation has come back. Nerves can regenerate and I'm hoping my nerve damage down there will heal too.
I think a formal complaint is the way forward. And if "all" it achieves is to make you fell better, then I think that's a pretty big achievement. Another thing that REALLY annoys me is that my birth has doubtless been recorded as a great success - 1st timer, natural VB, not instrumental, etc etc. Even my doula thought that it had all gone swimmingly, despite the fact that I was clearly terrified during the birth and she knew I was traumatised afterwards. Well, actually no. It's been a disaster. A formal complaint will go some way to informing them of this, which I feel is really important. Formal complaints can't be ignored and have to be investigated and reported upon. So making one will make a difference by forcing the department concerned to examine the issues you raise. I think you usually have 12 months from the date of the incident to complain, so you've got a few months yet. X

breatheslowly Fri 22-Jul-11 21:30:33

My experience of looking at my notes was quite different. They were clearly far less detailed. So the tearing I had in 4 different directions including an extended episiotomy was just recorded as 2nd degree tear. There was nothing about my sleeping or eating. I think they took the approach of writing down the minimum necessary and I don't think anyone really read them between hand overs.

WorrisomeHeart Fri 22-Jul-11 21:34:42

My notes say that bfing was established and going well.. Which is odd considering I left hospital having only latched DS 3 times over the 5 days and was solely expressing and feeding via bottles. hmm

theborrower Fri 22-Jul-11 21:42:07

Cardamomginger - I'm not surprised you're angry. Bloomin' hell! Hope your complaint goes well (if you see what I mean). And sorry to hear that you've had a terrible experience.

timidviper Fri 22-Jul-11 21:43:28

When I was expecting DD the consultant asked me did I understand that I would not have a birth like that of DS. I was rather puzzled and asked him to explain at which point he told me that I would have to accept intervention sooner if things did not progress as both DS and I were at risk of death for some time during the labour and birth.

I had begged for intervention for hours but the staff at the first hospital told me that things would progress naturally and not to worry. Eventually after 27 hours of labour and DS passing meconium a doctor attended and did a Keillands rotation. At no point were we told of any risks before, during or after yet something had been documented.

Luckily DS and I were both healthy so I never had cause to ask to see them.

BeautifulBirths Fri 22-Jul-11 22:38:19

I'm sorry to hear all this. Ask to speak to the head of midwifery and/or your midwife who cared for you. They can go over notes explain and appologise. Won't change it but may make you feel better. If it was a traumatic birth though she may have mentioned it during the suturing but you didn't hear or can't remember? You have lots of hormones, endorphins etc which help us women forget what went on at that time. Please go back to your midwife and hopefully you'll feel a bit better.

cardamomginger Sat 23-Jul-11 23:50:39

Breathes & timid - that's terrible. Hope you are both OK now.
Worrisome - yeah I think they just write in stuff as they want.
Beautiful Thanks for your sympathies. But I hope you don't mind me saying that I find your comment that what with all the hormones, etc I might have forgotten what I was told fairly patronising. I clearly remember the discussion about the extent of the tear - I was very concerned about it and asked several questions and for clarification. I made sure that DH took on board what was being said. No mention was made of a clitoral tear. I can also remember quite clearly that I did not sleep a wink that night and that I did not eat (in fact I wasn't 'allowed' to because I had a syntocinon drip and had been told by the SPR not to eat or drink. Neither am I confused about the fact that it was my doula who gave me a bed bath with the comment, 'I guess I'd better help you clean up given that none of the staff are going to.' In any event, this all pales into comparison against what will be the main focus of my complaint, which is that I tore through my pelvic floor completely, there is no mention of this in my notes, they did not notice and they did not stitch it. I'm afraid that just going back to my MW, even if such a thing were possible, which according to the labour ward it isn't because I have 'left it too late', will not make me feel any better.

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