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Women left in extreme pain from invasive hysteroscopy procedures hit out
Patient Safety Learning posted a news article in News
Women have been left in extreme pain from an invasive procedure that’s been described as the “next big medical scandal”. The Campaign Against Painful Hysteroscopy (CAPH) has collated more than 3000 accounts of “pain, fainting and trauma during outpatient hysteroscopy” throughout the UK – including more than 40 so far from Scotland. CAPH said female patients are being subjected to barbaric levels of pain and claim hospitals prioritise efficiency and cost-cutting over their needs and welfare. The group believes the issue could become as bad as the vaginal mesh scandal, which saw women left in severe pain and with life-changing side effects after being treated with polypropylene mesh implants for stress urinary incontinence and pelvic organ prolapse. Katharine Tylko, of CAPH, said: “Severely painful outpatient hysteroscopy is the next medical scandal after vaginal mesh. Cheap, quick and easy-ish NHS outpatient hysteroscopy without anaesthesia/sedation causes severe pain/distress/trauma to approximately 25 per cent of patients.” Margaret Cannon, from Rutherglen in Lanarkshire, told how she had an “excruciatingly painful” hysteroscopy at Stobhill Hospital in April 2020 without anaesthetic or analgesia. She said: “I am a qualified nurse and midwife, so have good insight into how all the medical and nursing professionals failed me. I had been told to expect mild cramp and I kept thinking, ‘What’s wrong with me that I can’t tolerate the pain?’ I felt violated and assaulted.” She felt so strongly about her experience that she complained. When she finally received a response, she said it “was dismissive and none of my points were addressed”. Read full story Source: Daily Record, 19 March 2023 See also our 'Painful hysteroscopy' thread in the hub Community.- Posted
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Painful hysteroscopy
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*Trigger warning. This post includes personal gynaecological experiences of a traumatic nature. What is your experience of having a hysteroscopy? We would like to hear - good or bad so that we can help campaign for safer, harm free care. You can read Patient Safety Learning's blog about improving hysteroscopy safety here. You'll need to be a hub member to comment below, it's quick and easy to do. You can sign up here.- Posted
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Informed consent The NHS defines informed consent as: “… the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead.”[4] This is often broken down into the acronym BRAN (Benefits, Risks, Alternatives and doing Nothing).[5] The landmark UK Supreme Court judgment Montgomery v Lanarkshire Health Board case in 2015 reaffirmed this principle in law, setting out the legal duty of doctors to disclose information to patients about risks.[6] However, despite this legal obligation, far too often we see cases of avoidable patient harm where there has been failure of informed consent. Although this is an issue that can impact any patient, this is often particularly notable in health conditions and areas of care that predominantly affect women. In this blog, we will look at three areas where failures of informed consent have patient safety implications for women: receiving information about benefits and risks being told about alternative treatments and options, and the impact on patients after failures of informed consent. Receiving information about benefits and risks To provide informed consent, patients need to be made aware of the benefits and risks of a procedure or treatment before deciding whether to proceed. The Independent Medicines and Medical Devices Safety (IMMDS) review highlighted this as a recurring point of concern in medical interventions predominantly affecting women. This Review examined how the healthcare system responded to the harmful side effects of three medical interventions: hormone pregnancy tests, sodium valproate and pelvic mesh implants, uncovering a truly shocking degree of avoidable harm over a period of decades.[7] Let’s look at the case of sodium valproate; an epilepsy treatment that is potentially harmful to the developing fetus and can lead to physical deformities and learning difficulties in children if taken when the woman is pregnant – a condition known as Fetal Valproate Syndrome. The IMMDS Review highlighted that many pregnant women who were taking sodium valproate as an epilepsy treatment did so without knowing that this could harm their unborn child. What is particularly concerning in this example is that it is not a historic problem. Despite national attention on the findings of this Review and the serious harm caused, there are still women taking sodium valproate during pregnancy today who are not aware of the associated risks. This has been identified as one of the three top priorities areas of work for Dr Henrietta Hughes, the new Patient Safety Commissioner for England.[8] Information and alternative treatments and options Having choices, and the opportunity to discuss different options, is an important part of informed consent. When considering healthcare treatment patients often find themselves reliant on healthcare professionals to tell them about the full range of options. An example of where having this choice may not always be the case, and can be detrimental to women’s health, is hysteroscopy. Hysteroscopy is a procedure used as a diagnostic tool which involves a long, thin tube being passed through the vagina and cervix, into the womb, often with little or no anaesthesia. While some women do not find the procedure painful, many experience severely painful and traumatic hysteroscopies, raising significant patient safety concerns.[9] One key issue commonly highlighted is that women are not always being told of the possibility of severe pain or are not being offered the full range of pain management options available to them for a hysteroscopy. Many are just told to expect mild period-like cramping and to take simple analgesics, such as paracetamol, beforehand.[10] [11] Patient feedback suggests that approaches to this across the country are not consistent. Some women receive no information about pain management options, while others are able to discuss various options, including a general anaesthetic. At Patient Safety Learning we have recently highlighted the need for improvements in this area, calling for an independent review of these services, including the application of informed consent.[9] There are also concerns that the choices offered to women may vary depending on their race. Last year the organisation Five X More published a survey into Black women’s experiences of maternity services in the UK which raised serious concerns about inconsistences in how Black and Black mixed women were approached compared to white women or their own family members who were white. Examples it highlighted included: "... some women felt that they were not always provided with the opportunity to make informed decisions (“I didn’t request pethidine yet I was given it”); that they were pressured into making decisions about treatment (“…I found the attitude for an induction to be very forceful”); that procedures were performed without consent (“…She said she wanted to see how dilated I was, but also carried out a cervical stretch without my prior knowledge or permission), and that medication was administered, sometimes by junior or student members of staff without permission”.[12] Impact after failures of informed consent As well as the concerns and issues around lack of informed consent at the time of care and treatment, it can also have long-reaching consequences afterwards for the patient. An example of this is women who have been harmed by surgical mesh. As noted in the IMMDS Review, many women reported a failure of informed consent: “… they never knew they had mesh inserted, or where they gave consent for ‘tape’ insertion they did not know they were being implanted with polypropylene mesh”.[7] Many women harmed by mesh have been forced to live with a constant reminder of this lack of consent and abuse of trust, as they deal with significant health problems and difficulties in accessing mesh removal through the NHS.[13] [14] [15] It is hard to overstate the emotional and psychological impact this can have on a patient. These experiences serve to significantly undermine trust in healthcare and healthcare professionals. Returning to the example of hysteroscopy procedures, in sharing their experiences with us on the hub many women spoke about ongoing feelings of violation following experiences of severe pain. These feelings of violation are often exacerbated by the fact that they were not informed of the risk of severe pain beforehand. Most shockingly perhaps, there are cases where women asked for the procedure to be stopped due to the level of pain and their wishes were not followed.[9] This raises serious questions around how patients are responded to when actively withdrawing their consent. In some cases the associated trauma has translated into a reluctance to attend other important appointments, such as cervical smear tests, potentially compromising their long-term health. This dangerous knock-on effect has also been raised by women who experienced painful contraceptive device (IUD) procedures, and again did not feel adequately informed beforehand.[16] Influence of paternalistic, sexist, and misogynist attitudes Absence of informed consent is not an issue that solely affects women. However, as we have shown, there are many examples of consent issues that relate to care and treatment predominantly affecting women. Failures of informed consent are driven by a range of factors, including a lack of training, extremely busy working environments and communication difficulties. However, in the cases discussed here where informed consent has failed, many of those women affected have spoken about this being interwoven with concerns about paternalistic, sexist and misogynistic treatment. There is now a wealth of evidence around this issue, and more broadly about a massive gender health gap which impacts on women’s care and treatment in a range of ways, from the point of diagnosis through to treatment and aftercare.[17] [18] Far too often women still find themselves met with defensive and unresponsive attitudes from the healthcare system and can often feel belittled, dismissed and patronised.[19] Women’s Health Strategy The gender health gap is becoming widely acknowledged and last year the UK Government published a new Women’s Health Strategy for England seeking to close this gap. One area this Strategy identifies is the need for improvements in informed consent and shared decision-making to support women to make informed decisions about their health and care. It also refers to ongoing work by the Royal College of Obstetricians and Gynaecologists to develop new consent guidance for nine gynaecological procedures. The Strategy includes a six-point long term plan for making a transformational change in women’s healthcare, and tying into the #EmbraceEquity theme of this year’s International Women’s Day one of these points is: “Ensuring women’s voices are heard – tackling taboos and stigmas, ensuring women are listened to by healthcare professionals, and increasing representation of women at all levels of the health and care system.”[20] The ambition behind this strategy is welcome, as is the Government’s decision to appoint a new Women’s Health Ambassador, Dame Lesley Regan, to drive system-level changes to close the gender health gap.[21] However, whether these good intentions will be translated into real progress and improvements in women’s health is yet to be seen. In talking about implementing changes, the Women’s Health Strategy notes the wide and varied range of stakeholders that will need to be involved in this effort and states that the Government ‘will develop a delivery plan for the commitments set out in this strategy’. However, there is currently no timetable for this or indication of what resources may be allocated to support this work. Improving informed consent Patient Safety Learning believes that plans to improve informed consent need to be a core part of the Government’s delivery plan for its Women’s Health Strategy. The Strategy refers to the increased use of patient decision aids and conversation aids to support informed consent, including a series of digital tools called iDecide to better support informed decision-making in labour.[22] While such tools are important, they need to form part of a wider programme of work to create meaningful change. The IMMDS Review highlighted some important points around this, which we believe should inform the Government’s approach in this area: Greater thought needs to be given to help patients better understand risk. Information around consent should be shared in way that is clear and meaningful. Talking to, or hearing from, others who have experienced the same intervention with or without complications could be hugely beneficial and should be considered as part of the informed consent process. Patient decision aids should be validated, standardised for each procedure and be jointly developed with patients, reflecting their experiences and outcomes. Commenting on this issue, Patient Safety Learning’s Chief Executive Helen Hughes said: “All too often, female patients are not given the information needed to make a truly informed decision about their own health. Not only is it unlawful, but it can lead to long-lasting physical and psychological harm. Through its Women’s Health Strategy, the Government has an opportunity to significantly improve informed consent across the NHS, ensuring patients receive consistent access to all the information and options they need in relation to their care. But these changes cannot take place in isolation, they must also form part of a wider change in approach to tackle the persistence of paternalistic attitudes that treat women as passive participants in their care.” Work around informed consent in the Women’s Health Strategy, and this broader culture change, will need to be accompanied with clear leadership, delivery plans and effective resourcing if we are to move towards a safer healthcare system for women. Share your views We would love to hear your thoughts and feedback on the content of this blog. To leave your comments below, please sign up to the hub. If you would like to share your experiences and insights on any of the issues raised, you can also get in touch with the Patient Safety Learning team at content@pslhub.org. Related reading For International Women’s Day 2023, we have picked out seven resources to highlight and evidence some of the key patient safety issues concerning women’s health equity in our latest Top picks article. References Patient Safety Learning. Dangerous exclusions: The risk to patient safety of sex and gender bias, 8 March 2021. Patient Safety Learning. Medicines, research and female hormones: a dangerous knowledge gap, 8 March 2022. International Women’s Day 2023 Theme. Last Accessed 27 February 2023. NHS England. Consent to treatment. Last Accessed 27 February 2023. Julie Smith. Informed consent: what is it? 21 December 2020. UK Supreme Court, Montgomery v Lanarkshire Health Board, 2015. The IMMDS Review. First Do No Harm: The report of the Independent Medicines and Medical Devices Safety Review, 8 July 2020. Patient Safety Commissioner for England. Patient Safety Commissioner: 100 Days Report, 2 February 2023. Patient Safety Learning. Hysteroscopy: 6 calls for action to prevent avoidable harm, 1 March 2023. Campaign Against Painful Hysteroscopy. CAPH Survey Results – Hysteroscopy Action. Last accessed 27 February 2023. Patient Safety Learning’s the hub. Community Forum, Painful Hysteroscopy. Last accessed 1 March 2023. Five X More. The Black Maternity Experiences Survey: A Nationwide Study of Black Women’s Experiences of Maternity Services in the United Kingdom, 24 May 2022. Kath Sansom. ‘Mesh removal surgery is a postcode lotter’ – patients harmed by surgical mesh need accessible, consistent treatment, 2 December 2021. Anonymous. “There’s no problem with the mesh”: A personal account of the struggle to get vaginal mesh removal surgery, 1 May 2022. Patient Safety Learning and Sling the Mesh. Specialist mesh centres are failing to offer adequate support to women harmed by mesh, 25 August 2022. Sophie, Medical trauma from IUD fitting: it’s not just five minutes of pain for five years of gain, 10 January 2022. Sarah Graham. Rebel Bodies: A guide to the gender health gap revolution, 5 January 2023. Caroline Criado Perez. Invisible Women: Exposes data bias in a world designed for men, 5 March 2020. Sarah Graham. Gender bias: A threat to women’s health, 4 August 2020. Department of Health and Social Care. Women’s Health Strategy for England, 30 August 2022. Department of Health and Social Care. Dame Lesley Regan appointed Women’s Health Ambassador, 17 June 2022. iDecide. iDecide: Your birth, your decisions. Last Accessed 2 March 2023.- Posted
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Patient safety concerns We know that outpatient hysteroscopy is a valuable diagnostic procedure. When patients are given all of the available information, offered appropriate pain relief options and feel treated with respect and dignity, experiences of a hysteroscopy procedure can be good. But, as we have heard all too often, in many cases this is not what patients are experiencing and a number of significant safety concerns persist. Risk of severe pain There are hundreds of personal accounts from women who have experienced very high levels of pain and associated trauma during and/or following a hysteroscopy procedure[7-9] This is supported by research papers, showing unacceptable percentages of patients scoring their pain as medium-to high.[10][11] In addition, we have heard accounts of longer lasting pain and complications, physical harm and post-traumatic stress disorder following hysteroscopies.[12][13] Studies show clinician perception of patient pain is not an accurate measure, tending to underestimate the pain experienced.[14][15] This raises questions about the value of pain and tolerability assessments made by the clinicians undertaking hysteroscopy procedures and the impact this bias has on treatment. “After the procedure, Martha understandably felt violated, but sadly that was far from the end of her ordeal. She had burning pain for weeks, mixed with a loss of feeling in her groin. She developed repeated bladder infections and double incontinence, and her muscles started wasting. She had difficulty standing and walking. Eventually, Martha was told that she had post-operative nerve damage. To put the cherry on the cake, I understand that the doctor who did this to Martha recorded her pain score as just one out of 10.” Lyn Brown MP speaking in a House of Commons debate Absence of informed consent It has become clear that many women are not fully informed when consenting to a hysteroscopy procedure. As set out by national guidance, they should be given all of the options available to them beforehand. This should include information outlining the benefits, risks, alternatives and consequences of opting not to proceed with any procedures.[16-18] Women are not always being told of the possibility of severe pain or offered the range of pain management options available to them for a hysteroscopy. Many are told to expect mild period-like cramping and to take simple analgesics, such as paracetamol, beforehand.[19][20] Lack of guidance to support triage Although it is difficult to predict who will experience severe pain during a hysteroscopy, conversations between the patient and the clinician around medical history could help to identify who might be more susceptible. For example, women who have experienced sexual trauma, found gynaecological procedures very painful in the past and those who have not given birth may be more at risk.[21][22] There is little available guidance to support clinicians in having these conversations to help patients feel informed of their individual risks of pain. Physical and psychological violation Women have spoken about feelings of violation during and following their hysteroscopy procedure, particularly where they do not feel they have been adequately prepared and informed beforehand. There are also serious concerns that some women have not had their wishes listened to or acted on when they have asked for the procedure to be stopped. In such cases, the physical and psychological trauma becomes entwined and heightened, as many women feel that both their body and trust has been harmed. In addition, many women have described having their pain or concerns dismissed, belittled, or disbelieved, often linking this to misogynistic or paternalistic approaches and language.[23-25] Negative impact on future health outcomes The loss of trust that comes from feeling uninformed before experiencing high levels of pain during a hysteroscopy, can understandably impact the relationship a patient has with our healthcare system. This has inevitably left some fearful to attend important appointments in future, for example cervical smear screenings. The stark reality is that these harmful experiences have potential to negatively impact future diagnoses, treatments and health outcomes. Patient Safety Learning has provided an online forum for women to share their experiences of hysteroscopy. This has had over 60,000 views to date, helping amplify the voices of many women who have often been dismissed or left unheard. These testimonies have informed our work on this topic, helping us to understand the key safety concerns and indicating what actions may be needed to prevent future avoidable harm. Patient Safety Commissioner and discussions in the House of Commons Patient Safety Commissioner’s first 100 days report Last year Dr Henrietta Hughes was appointed as the first Patient Safety Commissioner for England. She is an independent champion for patients and seeks to drive improvements in the safety of medicines and medical devices.[26] In a recent report reflecting on her first 100 days in post, she highlighted that 6% of the initial correspondence she received related to painful experiences of gynaecological procedures, such as hysteroscopy.[27] Although her initial priorities for this year do not include this topic, this is one of the issues on her radar and we look forward to hearing more detail about the concerns raised and how she plans to address these moving forward. Discussions in Parliament In addition to patients and campaigners raising safety concerns relating to hysteroscopy procedures, this was also the subject of a recent debate in the House of Commons, [28] led by Lyn Brown MP. It was the 10th time she has brought the issue before Parliament. In her speech, Lyn Brown noted that a third of women experience very high levels of pain, and drew on the case of ‘Martha’ who was seriously injured during her hysteroscopy. She also expressed concern that a proposed target of aiming for 90% of hysteroscopy happening within outpatient rooms, suggested by the Getting It Right First Time programme, could exacerbate the number of cases where patients do not receive appropriate pain relief options. Lyn Brown also raised concerns around: The lack of formal data collection by the NHS on cases of painful hysteroscopy. Potentially embedded views among gynaecologists regarding pain and patient experiences of this procedure. Patients who have negative experiences in relation to hysteroscopy being afraid to access important health procedures in future, with a long-term impact on their health. This debate was responded to on behalf of the Government by Maria Caulfield MP, Minister for Mental Health and Women’s Health Strategy. In her response, Maria Caulfield stated that she would be meeting with patient group, The Campaign Against Painful Hysteroscopy, to discuss the issues further. She also said that she had asked the Women’s Health Ambassador, Dame Lesley Regan, to discuss the issues surrounding hysteroscopies further with the Patient Safety Commissioner for England, Dr Henrietta Hughes. The Minister also highlighted the importance of translating the imminent Royal College of Obstetricians and Gynaecologists (RCOG) guidance into clinical practice. Westminster_Hall_31_01_23_15_39_50 (1).mp4 Maria Caulfield MP New guidance The new guidance referred to by the Minister was subsequently published by RCOG on 7 February 2023. This good practice paper, Pain relief and informed decision making for outpatient hysteroscopy, has been written for healthcare professionals who are involved in providing outpatient hysteroscopy.[29] Patient Safety Learning submitted a response to the consultation on this Paper last year, with the aim of supporting safer hysteroscopy care and improved patient experience.[30] Reflections on the new good practice paper We welcome the publication of this new paper for healthcare professionals, to help them understand some of the steps they can take to improve hysteroscopy safety. We were pleased to see this paper acknowledge that a third of women experience significant pain during hysteroscopy, scoring their pain at 7 out of 10 or higher. There was also a clear effort to include advice around compassionate care before, during and after the procedure. We also welcome the emphasis on the importance of ensuring women have full information beforehand and have been told of all of the available options. We do however note the following concerns in relation to the guidance: There are several references made to using simple over-the-counter painkillers beforehand ‘unless there are contraindications’. A contraindication is when a patient has something (such as a symptom or condition) that makes a particular treatment or procedure inadvisable. There is however no guidance around what should be considered a ‘contraindication’ in relation to a hysteroscopy procedure, and how best to triage patients accordingly when it comes to pain relief options and individual risk of severe pain. On several occasions it refers to patients experiencing period-like pain, or a variant of this term. This is quite an imprecise description that some women may not find helpful in making an informed decision about their care, as patients experience period pain very differently. Asked for their thoughts on the new guidance, Katharine Tylko from the Campaign Against Painful Hysteroscopy, also highlighted shortcomings in this new paper, stating: "This guidance does not cover all of the options for hysteroscopy including IV sedation with analgesia, procedural sedation analgesia, spinal anaesthesia and light general anaesthetic. Instead it continues to promote a 'trial by outpatient hysteroscopy’ approach, where many women suffer such intolerable pain that the procedure has to be abandoned. Often, it is only then they are allowed to arrange a hysteroscopy with the aid of an anaesthetist". Translating guidance to practice Despite the issues we’ve highlighted, if implemented consistently and well, the good practice paper has the potential to raise standards of hysteroscopy care and reduce the current postcode lottery of experiences patients have of this procedure. However, we know from patient feedback that previous hysteroscopy guidance has not been consistently followed, leading to unacceptably poor experiences and unsafe care. This failure to translate what we know will improve patient safety to what is done in practice is not unique to hysteroscopies. It happens in a range of other areas, as detailed in our report last year Mind the implementation gap'[31] Questions therefore remain around how effectively the new RCOG guidance will be implemented and whether this will lead to improvements in patient safety. Following on from this good practice paper, RCOG have now launched a consultation into a new Green Top Guideline on hysteroscopy.[32] Green Top Guidance is comprised of evidence-based recommendations that are intended to assist clinicians and individuals in making decisions about appropriate tests or treatment for specific conditions or circumstances. This could potentially have a significant impact on how hysteroscopies are approached in the NHS.[33] This consultation is open to patients and professionals and provides further opportunity to influence and inform hysteroscopy practice. Building on our comments here, we will be formally submitting a response prior to the deadline on the 13 March 2023. We would welcome hearing your thoughts on this to help inform our response, which you can share with us directly by emailing hello@patientsafetylearning.org. Find out more about the consultation. Calls for action Considering the patient safety concerns detailed in this blog, in the context of recent policy developments nationally, Patient Safety Learning is calling for the following to improve patient safety in hysteroscopy procedures: An independent review of hysteroscopy services in the NHS. This should assess the scale of psychological and physical harm, the application of informed consent, barriers to safe care and the role of sexism and misogyny in the treatment of women undergoing hysteroscopy procedures. We believe it would be beneficial for this to be supported by the Patient Safety Commissioner for England and the Healthcare Safety Investigation Branch. Publication of a clear implementation plan for the new RCOG good practice and green-top guidance. This should include timeframes for implementation, measures of success, plans for working with patients and other key stakeholders, details of associated staff requirements and training, and information on how progress will be reviewed, monitored and reported on. NHS England should mandate the collection of patient reported outcome measures for all hysteroscopy procedures and make this data publicly available. Severe pain during hysteroscopy procedures, as reported by patients, to be recorded by healthcare professionals as a patient safety incident. Examples of hysteroscopy good practice should be published by NHS England and shared widely to clinicians, service managers and patient safety specialists, to inform improvements in outpatient hysteroscopy so that all patients can benefit. Research should be commissioned to identify the factors that lead to patients being at greater risk of experiencing high levels of pain during outpatient hysteroscopy. This should then be used by NHS England and RCOG to create evidence-based guidance to support clinicians in identifying patients most at risk of severe pain during hysteroscopy. Final thoughts Recent activity surrounding hysteroscopy safety has kept these important conversations going among clinicians, patients and MPs. Positive steps have been taken and verbal commitments have been made. Momentum must not stop here. Every week, patients continue to share experiences of severe pain, uninformed consent, misogynistic care and lasting psychological trauma. There is clearly much more to be done to ensure patients have access to safe, respectful hysteroscopy care and are always provided with the information and options necessary to be able to provide truly informed consent. The RCOG guidance aims to achieve optimal outcomes for women. But without a robust implementation strategy, associated resources and genuine engagement with patients, hysteroscopy experiences will inevitably continue to vary and harm will persist. Share your insights If you would like to share your insights around hysteroscopy, please contact us at content@PSLhub.org. References Harrison, R, Kuteesa, W, Kapila, A. Pain-free day surgery? Evaluating pain and pain assessment during hysteroscopy. Journal of Anaesthesia. 2020. Royal College of Obstetricians and Gynaecologists. Pain relief and informed decision making for outpatient hysteroscopy (Good Practice Paper No. 16). 2023. Morgan M, Dodds W, Wolfe C at al Women's views and experiences of outpatient hysteroscopy: implications for a patient-centered service. Nurs Health Sci. 2004 Dec;6(4):315-20. Patient Safety Learning. Improving hysteroscopy safety. 2020. Hansard. House of Commons Debate – NHS hysteroscopy treatment. 31 January 2023. Patient Safety Learning. Improving hysteroscopy safety. 2020. Patient Safety Learning’s the hub, Community Forum, Painful Hysteroscopy. 2020. Hysteroscopy Action. CAPH Survey Results – Hysteroscopy Action. Accessed 27 February 2023. Patient Safety Learning YouTube channel. 2020: Raising awareness about painful hysteroscopies - YouTube (see comments below the video). Accessed 27 February 2023. Harrison, R, Kuteesa, W, Kapila, A. Pain-free day surgery? Evaluating pain and pain assessment during hysteroscopy. Journal of Anaesthesia. 2020. Morgan M, Dodds W, Wolfe C at al Women's views and experiences of outpatient hysteroscopy: implications for a patient-centered service. Nurs Health Sci. 2004 Dec;6(4):315-20. Hansard. House of Commons Debate – NHS hysteroscopy treatment. 31 January 2023. Grandmother-of-three, 67, was left with PTSD after routine NHS medical check | Daily Mail Online Morgan M, Dodds W, Wolfe C at al Women's views and experiences of outpatient hysteroscopy: implications for a patient-centered service. Nurs Health Sci. 2004 Dec;6(4):315-20. Maguire K, Morrell K, Westhoff C, Davis A. Accuracy of providers' assessment of pain during intrauterine device insertion. Contraception. 2014 Jan;89(1):22-4 General Medical Council. Decision making and consent - ethical guidance. Accessed 27 February 2023. Royal College of Obstetricians and Gynaecologists. Pain relief and informed decision making for outpatient hysteroscopy (Good Practice Paper No. 16). 2023. NHS. Consent to treatment. Accessed 27 February 2023. Hysteroscopy Action. CAPH Survey Results – Hysteroscopy Action. Accessed 27 February 2023. Patient Safety Learning’s the hub, Community Forum, Painful Hysteroscopy. 2020. Havard Health publishing. When a pelvic exam is traumatic. 2019. Zayed S, Elsetohy K, Zayed M, et al. Factors affecting pain experienced during office hysteroscopy. Middle East Fertility Society Journal. 2015 Sep Vol. 20 (3): 154-158 Patient Safety Learning YouTube channel. 2020: Raising awareness about painful hysteroscopies - YouTube (see comments below the video). Accessed 27 February 2023. Patient Safety Learning’s the hub, Community Forum, Painful Hysteroscopy. 2020. Hansard. House of Commons Debate – NHS hysteroscopy treatment. 2023. Department of Health and Social Care. First ever Patient Safety Commissioner appointed. 2022. Patient’s Association. Patient Safety Commissioner for England, Patient Safety Commissioner: 100 Days Report. 2 February 2023. Hansard. House of Commons Debate – NHS hysteroscopy treatment. 2023. Royal College of Obstetricians and Gynaecologists. Pain relief and informed decision making for outpatient hysteroscopy (Good Practice Paper No. 16). 2023. Patient Safety Learning. Guidance for outpatient hysteroscopy: Consultation Response. 2022. Patient Safety Learning. Mind the implementation gap: The persistence of avoidable harm in the NHS. 2022. Royal College of Obstetricians and Gynaecologists. Green-top Guidelines No. 59 Outpatient Hysteroscopy 2nd Edition. Accessed 27 February 2023. Royal College of Obstetricians and Gynaecologists.. Developing a Green-top Guideline: Guidance for developers. 2020. Related reading House of Commons Debate – NHS hysteroscopy treatment (31 January 2023) Improving hysteroscopy safety, 6 November 2020. Through the hysteroscope: Reflections of a gynaecologist, 26 January 2021. Guidance for outpatient hysteroscopy: Consultation Response, 16 March 2022. Richard Harrison, “Pain-free hysteroscopy”, a blog by Dr Richard Harrison, 6 November 2020. Related video resources- Posted
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Over the past few years, Patient Safety Learning has heard from many patients about significant safety concerns relating to hysteroscopy procedures in the NHS.[1] From the countless women who have shared individual experiences on the hub to the conversations we have had with the patient group the Campaign Against Painful Hysteroscopy, it is clear that this is a topic needing further exploration and advocacy from a patient safety perspective. I therefore welcomed a recent opportunity to engage with healthcare professionals involved in hysteroscopy procedures and share these concerns when I was invited to attend the Association of Anaesthetists Winter Scientific Meeting 2023 last month. This is the Association’s flagship conference, attended by healthcare professionals from across the UK, and I was invited to contribute to a panel session. This was focused on differing approaches to sedation for hysteroscopy procedures in both operating theatres and outpatient settings. Healthcare professional perspective from Leeds Hysteroscopy is a procedure used as a diagnostic tool to identify the cause of common problems such as abnormal bleeding, unexplained pain or unusually heavy periods in women. It involves a long, thin tube being passed through the vagina and cervix, into the womb, often with little or no anaesthesia. The panel session started with a presentation about hysteroscopies from Dr John Dalton, Dr Tracy Jackson and Maria Chalmers, Specialist Nurse Hysteroscopist. Maria spoke about the approach to hysteroscopy at the Leeds Centre for Women’s Health, emphasising the importance of: appropriate patient consent for the procedure discussing the likelihood of pain in advance of obtaining consent the patient’s right to withdraw consent or stop the procedure at any time. They described how patients, if they wanted to, were invited to review the procedure on a screen, and reported that there had been positive feedback from patients who have undergone procedures with this option. They also spoke about the value of these procedures taking place in outpatient settings where possible, creating a quicker diagnostic assessment. In their presentation, they reflected on the importance of collecting data about patient outcomes and pointed to broadly positive satisfaction scores with their service. Reflections on consent It was positive to hear a strong emphasis on the importance of patient consent, both before and during a procedure. It is an area of concern that has been consistently raised with us by patients who have undergone hysteroscopy. Through our work, we know that a significant number of women are not given sufficient information beforehand about the nature of the procedure or the potential for high levels of pain. Many have told us they were not asked about their medical history or offered different options for pain relief. These patients often reflect that the consent they gave was therefore not informed. When a patient experiences unexpected levels of pain, they can understandably feel very unsafe. This can lead to lasting trauma and a fear of accessing further important procedures or screenings. It’s therefore essential to make sure women undergoing this procedure feel they have been given all the information available. Panel discussion I introduced the concerns being expressed by many women and this generated an open discussion with colleagues from Leeds and an engaged audience of anaesthetists, many of whom were unaware of the issues that patients are raising about outpatient hysteroscopy. In the panel discussion I spoke about the experiences that have been shared with us at Patient Safety Learning. Some women have described how the lack of forewarning about this procedure, coupled with the trauma of the experience itself, left them feeling that both their body and their trust had been violated. Many women have also described receiving little or no pain relief and not being given the information they needed to make an informed choice about their own care and their own bodies. More than 50,000 people have viewed our community discussion on the hub about hysteroscopy experiences, with many having shared awful experiences exhibiting bullying, lack of compassion, lack of information and horrendous pain. Recent research, published in the British Journal of Anaesthesia, shows that a significant number (17.6%) of women rate their pain during hysteroscopy as greater than 7/10, and only 7.8% report no pain at all.[2] We know that outpatient hysteroscopy is a valuable procedure when done right, with full information, appropriate pain relief options and informed consent. However, as we have heard all too often from patients, in many cases this is not what they are experiencing.[3] Similar concerns were raised this week in a debate in the House of Commons. When discussing the implementation of good practice in these procedures, Government Minister Maria Caulfield note that such guidance was only as effective as its implementation: “The royal college is important because it can bring clinical change on the ground, but it is not enough just to assume that its updated guidance will be enough to change what happens in practice.”[4] Patients and campaigners are not unsupportive of hysteroscopy as a procedure. However, I shared our view, and that of many, that patients should not be expected to tolerate extreme pain or inconsistency of service. I emphasised a need for: increased efforts to ensure that good practice is shared widely and consistently applied. more research to better inform risk assessments about which women are most likely to affected by severe pain. ensuring that all those healthcare professionals involved in these procedures understand the importance of listening to and responding patients, giving women a range of pain relief options and providing the option to stop the procedure. It was useful to discuss with Maria and other clinical colleagues the value of hysteroscopy and the efforts that some centres are making to ensure that patients’ needs are met, and their voices heeded. It was helpful also to see in person the responses of anaesthetists in the room. There was, in some cases, clear concern about the negative experiences that have been shared with Patient Safety Learning by patients. Then we had some interesting reflections on the pain scores presented by the staff at Leeds. Many anaesthetists expressed shock that despite the good service being provided there, median pain scores are 5 out of 10. Some anaesthetists commented that patients wouldn’t be let out of recovery rooms by nursing staff with that extent of pain, and some said that they themselves wouldn’t want to undergo such a procedure in an outpatient setting with that median pain rating. The discussion was an important multi-disciplinary conversation of the value of hysteroscopy as a procedure while highlighting the very real concerns that women are experiencing when Royal College of Obstetricians and Gynaecologists guidelines are not being met consistently. The opportunity to engage in discussion with clinicians who are aiming to put patients’ experience at the heart of their service was much appreciated and we’re going to follow up with Maria and John to hear more about their service and the plans they have for continual improvement and for the best experience for women. We applaud the Association of Anaesthetists for highlighting these issues and aim to engage further to increase awareness of hysteroscopy pain and the need for urgent action. We look forward to sharing the recording of the session via the hub as soon as it becomes available. Join the conversation There is much work still needed to raise awareness of the patient safety issues concerning hysteroscopy procedures and to make the changes required to ensure good practice is applied consistently across the country. In the coming weeks, we will be publishing a new policy blog looking at this in greater detail and considering what more needs to be done to improve patient safety. In the meantime, if you have an experience you would like to share with us, please do get in touch. Perhaps you are a healthcare professional with insights to share on this topic? A patient who has had a hysteroscopy? A researcher? We'd love to hear from you if have a different perspective to add. You can join the conversation on the hub or get in touch with us directly by emailing content@pslhub.org. References 1. Campaign Against Painful Hysteroscopy, Open letter to the Department of Health and Social Care, 20 October 2020 2. Richard Harrison, William Kuteesa, Atul Kapila, Mark Little, Wiebke Gandhi, Deepak Ravindran, Carien M. van Reekum and Tim. V Salomons, Pain-free day surgery? Evaluating pain and pain assessment during hysteroscopy, 13 September 2020 3. Patient Safety Learning, Guidance for outpatient hysteroscopy: Consultation Response, 16 March 2022 4. House of Commons Debate, NHS hysteroscopy treatment, 31 January 2023- Posted
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7 November 2022 Dear Minister WOMEN’S ENDOSCOPY - HYSTEROSCOPY We are writing in support of the patient-led Hysteroscopy Action – also known as the Campaign Against Painful Hysteroscopy - to ask you to urgently commission more day-surgery theatre space and set up safely monitored IV sedation with analgesia for women’s endoscopy (hysteroscopy). Our call comes following research by the Royal College of Obstetricians and Gynaecologists showing 1 in 3 women having outpatient hysteroscopy experience severe pain. Lack of NHS day-surgery theatre space & sedation services means thousands of women every year are obliged to suffer excruciating pain while awake. This has been highlighted in numerous NHS audits. (Ref.1) A statement on the Royal College of Obstetricians & Gynaecologists website - 2018 - instructs gynaecologists to give women the choice of being awake or asleep for quick day case surgery. (Ref. 2) However, last year the NHS launched a new programme called Getting it Right First Time. GIRFT has set a target driven by the British Association of Day Surgery for the NHS to do 90 percent diagnostic and 50 per cent operative womb endoscopies without general anaesthetic or sedation. (Ref. 3) This cost-saving measure when applied to ablation of the womb lining is estimated to save £1,000 pounds per patient. (Ref. 4) The Health Service Journal in March 2020 analysed Hysteroscopy Action’s survey and found 240 women who reported not being given a choice to have general anaesthesia or sedation. (Ref. 5) A GIRFT webinar of July 2021 advocating day-case hysterectomy describes hysteroscopy as one of the ‘low-hanging fruits’ that has already been picked off, moved to and now only done in outpatients. (Ref. 6) Women are routinely having womb endoscopy in NHS outpatients with no sedation – just ibuprofen from home and ‘distraction technique’. In a pioneering, on-line dis-satisfaction survey Hysteroscopy Action has collected 3,000+ accounts of brutal, barbaric pain, fainting and trauma during outpatient hysteroscopy. (Ref. 7) Many gynaecologists are not informing patients of the 1 in 3 risk of severe pain if they have hysteroscopy awake. Women are misled to believe the procedure is a bit like a smear test - mildly uncomfortable to moderately painful. For 1 in 3 women this is not the case and the procedure is agonising. In some cases women are left traumatised, distrustful of doctors, unable to have sex or afraid of further procedures. Hysteroscopy Action is counselling hundreds of patients with PTSD, who for various medical reasons – e.g. no vaginal delivery, previous cervical surgery – were never candidates for hysteroscopy awake. Hysteroscopy involves a rigid knitting needle-like rod with a tiny camera and surgical tools passed through the cervix into the womb. The procedure ranges from diagnostic hysteroscopy with biopsy to detect cancer to operative removal of polyps and small fibroids. We the undersigned are calling for women to have informed consent and choice about whether and what type of anaesthesia or sedation they want. Baroness Shaista Gohir Charlotte Kneer MBE, DL Helen Hughes, Chief Executive, Patient Safety Learning The women’s health charity the Wellbeing of Women Elaine Falkner, Chair Campaign Against Painful Hysteroscopy CAPH committee members References 1. https://www.patientsafetylearning.org/blog/guidance-for-outpatient-hysteroscopy-consultation-response [7] RCOG, Good Practice Paper: Pain relief and informed decision-making for outpatient hysteroscopy and procedures, February-March 2022. https://s3-eu-west-1.amazonaws.com/ddme-psl/gpp-standards-in-outpatient-hysteroscopy-draft-peer-review.pdf “One third of women reported pain scores of 7–10 out of 10.” 2. https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/hysteroscopy-best-practice-in-outpatient-green-top-guideline-no-59/ The British Society for Gynaecological Endoscopy published this statement in December 2018: "Diagnostic hysteroscopy is a commonly performed investigation; it is safe and of short duration. Most women are able to have the procedure in an outpatient setting, with or without local anaesthesia, and find it convenient and acceptable. However, it is important that women are offered, from the outset, the choice of having the procedure performed as a day case procedure under general or regional anaesthetic. Some centres are also able to offer a conscious sedation service in a safe and monitored environment. It is important that the procedure is stopped if a woman finds the outpatient experience too painful for it to be continued. This may be at the request of the patient or nursing staff in attendance, or at the discretion of the clinician performing the investigation." 3. 4. 5. 6. A GIRFT webinar of July 2021 describes hysteroscopy as one of the ‘low-hanging fruits’ that has already been picked off, moved to and now only done in outpatients. 7. www.hysteroscopyaction.org.uk- Posted
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View an up-to-date spreadsheet of responses to the campaign’s ‘Dissatisfaction Survey’ so far. These are women’s lived experiences of horrendous outpatient hysteroscopy procedures have been shared with the Campaign Against Painful Hysteroscopy Survey.- Posted
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Dear Matt Hancock and Nadine Dorries, We ask the DHSC to make provision for all NHS Trusts to work with the RCoA and RCOG to establish safely monitored IV ‘conscious’ sedation with analgesia as a treatment option for hysteroscopy+/-biopsy. Currently, Trusts put almost all patients through Trial by Outpatient Hysteroscopy and only those patients who fail (usually due to acute pain) are allowed a GA. There is no routine option of IV sedation with analgesia or spinal anaesthesia. We ask too that NHS Trusts give all hysteroscopy patients upfront a fully informed ‘Montgomery’/ GMC CHOICE of: o no anaesthetic o LA / regional / epidural o IV sedation with analgesia o GA The choice should be made after thorough discussion with the patient about her medical history, risk factors and preferences. WHAT IS HYSTEROSCOPY? Hysteroscopy is endoscopy of the womb. Like colonoscopy, it’s used to detect cancer, pre-cancer and benign abnormalities. Hysteroscopy done in outpatients with miniature surgical tools enables the removal of polyps and small fibroids without an incision or general anaesthetic [GA]. Here the similarity with colonoscopy ends. For NHS colonoscopy, the patient is routinely offered a CHOICE of Entonox or IV sedation with analgesia. Some patients request and receive GA. The risk of perforation (and potential death) is less when performed on a patient under IV ‘conscious’ sedation than under GA. The NHS therefore wisely prefers colonoscopy under ‘conscious’ sedation to GA. NHS colonoscopy services aim to protect patients from severe pain. Apart from assuring basic human respect and dignity, the NHS recognises that people traumatised by a severely painful colonoscopy may delay or not return for vital cancer diagnosis or treatment. UPDATE FROM THE CAMPAIGN AGAINST PAINFUL HYSTEROSCOPY [CAPH] Severely painful outpatient hysteroscopy is the next medical scandal after vaginal mesh. Cheap, quick and easy-to-use NHS vaginal mesh kits helped the majority of patients, and saved precious time and resources. Cheap, quick and easy-ish NHS outpatient hysteroscopy [OPH] without anaesthesia/sedation causes severe pain/distress/trauma to approx. 25% patients and saves precious time and resources. Like the vaginal mesh campaigners, hysteroscopy patients who’d been seriously harmed by a flawed medical policy started asking questions. Hysteroscopists assured us that our excruciating and unforgettable pain was very ‘unusual’ and affected only 2% to 5% of patients. This statistic didn’t fit with patients’ observation of OPH clinics. So these ‘unusual’ women started googling, then exchanging stories via social media. Soon they formed into Facebook and Twitter groups. Involved politicians. Interrogated health authorities. Looked for medical explanations. Approached professional colleges and societies. Sought out empathetic and intelligent doctors. Studied the law of informed medical choice and consent. By 2014 a campaign was born, greatly assisted by Lyn Brown, MP (Lab, West Ham) who was prepared to stick her neck out for her constituents and for other women who’d been traumatised and dismissed as ‘incorrect’ in their perception of hysteroscopy pain. These women were clearly of the ‘wrong demographic’! Too anxious, had too narrow cervical canals, too tilted wombs, were too emotionally labile, too black, too white, too rich, too poor, too educated, too urban... By early 2020 the Campaign Against Hysteroscopy had amassed a google survey of 1,000+ hideous, predominantly NHS, stories. We sought stories of specifically painful hysteroscopy since our aim was to identify any common features in patients’ medical histories or the operating teams’ conduct of a painful procedure. We hoped that our findings would aid future patient selection and choice. We gave our results to the Presidents of RCOG and the British Society for Gynaecological Endoscopy. The survey’s free text was shocking: It was barbaric and one of the most painful experiences of my life including vaginal childbirth. I begged them to stop but they wouldn’t. It was like torture It was a terrible experience that I don’t think I will ever forget Just before lockdown, the Health Service Journal published an analysis of our survey [Matt Discombe, HSJ, 2 March 2020] “Around 520 women who attended NHS hospitals in England to undergo hysteroscopies — a procedure which uses narrow telescopes to examine the womb to diagnose the cause of heavy or abnormal bleeding — have told a survey their doctors carried on with their procedures even when they were in severe pain.” We continued our on-going survey, asking about pre/post-menopausal status; vaginal/caesarean delivery/nulliparity; endometriosis/dysmenorrhea/previous traumatic gynae; mental health; hospital information about pain risk; choice of LA/GA/IV sedation; pain-scores at different OPH stages; whether the hysteroscopist stopped if the patient was in pain/distressed; preferred mode of future hysteroscopy, etc. At the end of the survey we asked, “Is there anything else you’d like to tell us?” I was given a brown paper bag to breath into as I hyperventilate with the pain. The male consultant made fun of me. Anaesthetic should be compulsory, I have a high pain threshold but was most painful thing I have ever felt, still feeling traumatised after the event. Staff were appalling. 5 nurses and doctor laughed when they could see I was in terrible pain, shocking The pain after the procedure was finished, was excruciating, body started to go into shock. Ended up in A&E pumped full of morphine and admitted overnight for observation. Never again unless under GA. Ask them if they are in pain rather than asking them about their last holiday whilst their uterus is dilated. I am a midwife myself and spoke to the consultant explaining how anxious I felt regarding the procedure, as I had had a very painful / difficult removal of mirena coil previously and been told I had a cervical stenosis: I asked could I have sedation and was declined saying it would only be “ brief discomfort” and to just take painkillers a couple of hours before At one point that evening I was so confused and in pain, feeling sick and with a high resting heart rate that I nearly called an ambulance. I was alone. Nobody suggested I should have someone at home with me. Felt embarrassed because of yelling (due to the incredibly sharp pain) The doctor and nurse were fine but I was screaming in pain and doctor counted down from 10 to 1 to try to get me to hold on until she could finish it Gas and air made me feel light headed but made absolutely no difference to the pain I experienced. The Cumberlege Review ‘First Do No Harm’ of July 2020 categorised breaches of patient safety into themes. [https://www.immdsreview.org.uk/Report.html] Three of these themes sum up the current harms caused by an over-zealous, blanket NHS policy of reduced-cost OPH: Cumberlege Theme 1, "No-one is listening" – Hysteroscopists lack empathy; they ignore patients’ requests for GA and fail to stop when the patient is in distress. Cumberlege Theme 3, "I was never told" - Hysteroscopists fail to warn patients of the risk of severe pain and don’t tell patients upfront that they have the option of GA. Cumberlege Theme 10, "Collecting what matters" - Hysteroscopists are wilfully blind to Patient Reported Outcomes – they belittle and don’t record the patients’ own short-term, medium-term and long-term outcomes when these cause severe pain and PTSD. CAPH has frequently heard of hysteroscopists telling GPs that a crying patient “tolerated the procedure well”. WHAT IS THE DATA ON HYSTEROSCOPY PAIN? Just as with vaginal mesh, very few gynaecologists have systematically collected pain scores from all their OPH patients. When OPH pain-scores are reported in English journals usually only the median or mean scores are given. Hundreds of members of our Action/Support group were never asked for a pain-score. NHS OPH pain audits obtained by CAPH under the Freedom of Information Act shows that currently 1 in 4 NHS England hysteroscopy outpatients typically suffers severe pain of 7/10 or more. [ www.whatdotheyknow.com - see ‘Outpatient hysteroscopy/biopsy’] The British Society for Gynaecological Endoscopy’s 2019 bespoke 81-hospital survey of 5,000+ hysteroscopy patients from BSGE members’ own NHS clinics reports a mean pain-score of 5.2/10. So clearly it’s not the “mild discomfort” that most patient leaflets claim. Nor is it now feasible to say that severe pain is experienced by only 2-5% of patients. [ www.bsge.org.uk BSGE Ambulatory Care Network Meeting Feb 2020] CAPH has asked for the full range of BSGE members’ OPH pain-scores under FOIA. The British Journal of Anaesthesia this year published a review evaluating patients’ reported pain compared with hysteroscopists’ assessment of OPH pain over 8 years at Royal Berkshire Trust – a good clinic which is barely mentioned in our survey. [Harrison, Salomons 2020]. 17.6% of patients reported severe pain of 7/10 or more, while 7.8% reported no pain. The authors concluded that since patients were likely to experience pain then they should be warned of this. WHAT DOES THE NHS TELL PATIENTS ABOUT HYSTEROSCOPY PAIN? NHS hysteroscopy services appear to follow ex-Cancer Tsar Prof Sean Duffy’s opinion “Overall we think that too much emphasis is put on the issue of pain surrounding outpatient hysteroscopy.” [BMJ. 2001 Jan 6; 322(7277): 47] Patient leaflets almost invariably tell women to expect “mild discomfort”, on a par with moderate period pain. So, without any pre-op assessment the NHS pushes almost all women through Trial by Outpatient Hysteroscopy and reserves GA for those who ‘fail’. The womb endoscopy patient is NOT routinely offered the option of GA. If she asks for one, the request is usually declined – even before the covid-19 pandemic. Thus the vast majority of NHS clinics wilfully ignore the RCOG/BSGE 2018 statement instructing gynaecologists to offer all hysteroscopy patients the choice of GA up-front, and to stop an OPH if the patient is distressed. [https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg59/] Yes, there are some excellent, highly skilled and compassionate OPH clinics but, sadly, most put cost-effectiveness before compassion or ‘Montgomery’ informed patient choice, thus denying patients genuine informed consent. Most hospital leaflets tell patients to take over-the-counter meds from home. There is no pre-med in clinic. The woman gets a ‘vocal local’ – hairdresser chit-chat- pioneered in rural Kenya by Marie Stopes. The woman is sometimes held down if distressed and agitated. She may receive potentially painful injections into the cervix as ‘rescue analgesia’. Unfortunately the cervical LA doesn’t anaesthetise the top of the womb, from which the cancer-detecting biopsy is taken. [www.bsge.org.uk Ambulatory Care Network 2020 Keynote Speaker on ‘patchy and unpredictable’ cervical LA] WHAT DOES THE CAMPAIGN AGAINST PAINFUL HYSTEROSCOPY WANT? 1. Every single NHS hospital to use – at the very least – the RCOG patient leaflet (CAPH helped write) which mentions the risk of SEVERE pain outlines clinical risk-factors for severe pain offers patients upfront the option of a GA/IV sedation with analgesia 2. The DHSC and RCOG to work with the Royal College of Anaesthetists to train hysteroscopy teams and establish safe IV conscious sedation with analgesia as a CHOICE available to all womb endoscopy patients. 3. The DHSC to permanently remove any Best Practice Tariff or financial incentive which removes timely access to GA, IV sedation with analgesia or other anaesthetist supported service. 4. A pre-op assessment for all hysteroscopy patients, meaning an end to ‘See & Treat’ clinics, which often coerce women into polyp and fibroid removal without patients having time to consider whether they’d prefer GA/ IV sedation/ regional anaesthesia rather than a local which doesn’t anaesthetise the top of the womb. The current ‘One-Stop’ clinic endangers women who attend the clinic alone and then have to drive or travel home on their own, often in severe pain, bleeding and traumatised. This is unacceptable and must stop. 5. Standardised, regulated, updated high quality training and accreditation for all hysteroscopists together with up to date equipment. Hysteroscopists should be taught to recognise cohorts at high risk of severe pain, develop listening skills and treat women with respect. 6. Full transparency about the financial sponsorship of NHS hysteroscopists’ training by the medical devices industry and the resulting bias towards particular manufacturers’ preferences and cost-effectiveness rather than patient experience. 7. Severe procedural pain to be classed and recorded as a Serious Adverse Event. Yours faithfully, Elaine Falkner (Chair), Pamela Howe (Secretary), Jocelyn Lewis, Lorraine Shilcock, Denise Shafeie, Gill Johnson, Katharine Tylko (on behalf of) The Campaign Against Painful Hysteroscopy www.hysteroscopyaction.org.uk Twitter: @hysteroscopyA Facebook: Campaign Against Painful Hysteroscopy- Posted
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Outpatient hysteroscopy: RCOG patient leaflet
Claire Cox posted an article in Women's health
Key points: Outpatient hysteroscopy (OPH) is a procedure carried out in the outpatient clinic that involves examination of the inside of your uterus (womb) with a thin telescope. There are many reasons why you may be referred for OPH, such as to investigate and/or treat abnormal bleeding, to remove a polyp seen on a scan or to remove a coil with missing threads. The actual procedure usually takes 10-15 minutes. It can take longer if you are having any additional procedures. You may feel pain or discomfort during OPH. It is recommended that you take pain relief 1-2 hours before the appointment. If it is too painful, it is important to let your healthcare professional know as the procedure can be stopped at any time. You may choose to have the hysteroscopy under general anaesthetic. This will be done in an operating theatre, usually as a day case procedure. Possible risks with hysteroscopy include pain, feeling faint or sick, bleeding, infection and rarely uterine perforation (damage to the wall of the uterus). The risk of uterine perforation is lower during OPH than during hysteroscopy under general anaesthesia. Join the conversation on the hub about hysteroscopies.- Posted
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What is a Westminster Hall debate? Westminster Hall debates give Members of Parliament (MPs) an opportunity to raise local or national issues and receive a response from a government minister. Any MP can take part in a Westminster Hall debate. Waiting lists for gynaecological services Key points raised in this debate included: Emma Hardy MP noted that gynaecological waiting lists across the UK have now reached a combined figure of more than 610,000—a 69% increase on pre-pandemic levels. She stated that the number of women waiting over a year for care has increased from just 66 in February 2020 to nearly 29,000 two years later, at the end of April 2022—the highest number ever recorded. Lyn Brown MP highlighted concerns about hysteroscopy procedures and access to pain relief, noted that many patients are left with “the choice of either having the procedure without pain relief or waiting months to have it with pain relief." Feryal Clark MP talked about the postcode lottery of gynaecological waiting lists across the country, noting that “there has been an 89% rise in the north-west, a 97% increase in the midlands and a 144% increase in the east of England”. Emma Hardy MP stated that though specialist mesh treatment centres had opened, these have been “beset with problems over access, waiting times and cancellations”. Related reading RCOG - Left for too long: Understanding the scale and impact of gynaecology waiting lists (6 April 2022)- Posted
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Hysteroscopy is a procedure used as a diagnostic tool to identify the cause of common problems such as abnormal bleeding, unexplained pain, or unusually heavy periods in women. It involves a long, thin tube being passed into the womb, often with little or no anaesthesia. Concerns about painful hysteroscopy Patients, patient groups and politicians have raised serious safety concerns about outpatient hysteroscopy procedures for several years, highlighting cases of avoidable harm. Some women have described how the lack of forewarning, coupled with the trauma of the experience itself, left them feeling that both their body and their trust had been violated. Many received little or no pain relief and were not given the information needed to make an informed choice about their own care and their own bodies. On the hub we have highlighted concerns raised by the patient group the Campaign Against Painful Hysteroscopy[1] and individual patients who have shared their experiences with us. We also have the views of researchers[2] and healthcare professionals[3] on this issue. Informed by these insights, we identified several key patient safety concerns relating to these procedures in the NHS, around issues of informed consent, access to pain relief and the implementation of good practice guidance.[4] We’ve raised with these issues with the Department of Health and Social Care[5] and Health Ministers in Northern Ireland, Scotland and Wales(6), highlighting several key areas where we believe action is needed to improve hysteroscopy safety: National guidance for outpatient hysteroscopy to be consistently applied. Women to be provided with information and advice to inform their consent. Women to be offered and provided pain relief. Significant pain to be considered an adverse event, and recorded and reported as such. Research to assess the scale of unsafe care and pain, the extent to which women are suffering, and to inform the implementation of national guidelines. New guidance for healthcare professionals This month the Royal College of Obstetricians and Gynaecologists (RCOG) held a consultation on the first edition of new guidance which has been “written for healthcare professionals who are involved in providing outpatient hysteroscopy with the aim of optimising a woman’s experience and clinical outcomes.”[7] Below we summarise the key points included in Patient Safety Learning’s consultation response. You can find the full consultation document and our response at the end of this blog. Positive reflections Given the significant concerns that have been raised by patients about outpatient hysteroscopy in the NHS, we welcome the recognition by RCOG of the need to provide updated guidance to healthcare professionals. We were pleased to see the following included: Recognition that for some, this procedure can be an “unpleasant, and even traumatic, experience because of the amount of pain induced” and the importance of having clear and accurate information available so that patients can make informed choices about their treatment. Inclusion in the guidance of a specific reference to providing opportunities to reschedule appointments for patients who may have been unaware they had been scheduled for a hysteroscopy procedure, or who need more time to consider the options. Reference to ensuring “privacy, dignity and comfort” for patients undergoing this procedure. However, there were also several areas where we felt this guidance could have been improved. Patient engagement Patient engagement is key to improving patient safety. In our report, A Blueprint for Action[8], we identify this as one of the six foundations of safe care. We believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, in advocating for changes and in holding the system to account. This is especially important in the case of procedures such as hysteroscopy where patients and patient groups have expressed significant concerns about existing processes. In our response, we queried the extent to which the RCOG had engaged with patients and groups such as the Campaign Against Painful Hysteroscopy to ensure that their views and experiences could help to shape this guidance. Communication The guidance emphasises the importance of patients being sent and having access to information and online resources to help inform their decision making. We suggested it would also be helpful to provide this to primary care providers such as GPs. We have heard feedback from both patients and healthcare professionals suggesting that the quality of information currently provided by GPs about hysteroscopy can be variable. We also underlined the importance of this information being produced to a standard that is easily accessible and understandable for patients, such as the Patient Information Forum’s PIF TICK quality mark.[9] Resources for healthcare professionals Discussing the role of safety checks in this procedure, the guidance suggests that healthcare professionals could consider using a specially adapted checklist to ensure that “essential elements such as patient identity checks and pregnancy tests are recorded where appropriate and any medical concerns identified.” We said it would be helpful for RCOG to share a good practice example of this type of checklist. Patient-reported outcome data In our response, we highlighted the importance of ensuring that patient-reported outcome data is routinely collected following hysteroscopy procedures to identify any emerging patient safety concerns, and that this is made publicly available. Currently, severe pain after these procedures is not regularly reported by healthcare professionals, nor are there the mechanisms available for patients to share their experience. We are concerned that this may potentially result in under-reporting and this limits our ability to understand the true scale of this patient safety issue. We also stated our belief that incidences of significant pain should be considered an adverse event, being recorded, reported, and responded to appropriately. Consent The guidance places a welcome emphasis on the importance of patients understanding they can stop the procedure at any point. We suggested it may be beneficial to include a reference to the concept of a ‘two-step stop’, which was explained by Dr Saira Sundar in an interview on the hub as follows: “She can ask for the procedure to pause at any time and then I will tell her what part of the procedure we are at/time left to complete. I then ask her if she would like the entire procedure to stop based on this information.”[3] Language We expressed concerns about the some of the language used in this guidance. On several occasions it refers to patients experiencing period-like pain, or a variant of this term. While we appreciate pain is a complex issue, this is quite an imprecise description that some women may not find helpful in making an informed decision about their care, as patients experience pain differently. We believe there needs to be significantly more research into the extent of pain around these procedures, and better ways of describing what the pain might be like without referring to it in such general terms. We also expressed concerns that in the conclusion it states that “a minority of women will feel severe pain.” The guidance itself acknowledges that one third of women reported pain scores of 7-10 out of 10. While this is technically a ‘minority’, we are concerned that use of this term underplays a significant proportion of women’s lived experiences. Training Towards the end of the document, there is a reference to the importance of training for those providing outpatient hysteroscopy services. However, specific training needs are not covered in this guidance. We believe it is important that staff who undertake these services should receive standardised and regulated training. This should include the risks of severe pain, clinical factors that make someone more susceptible, the limitations of clinician perception in assessing pain, the importance of listening to the patient throughout and the application of consent guidelines. Skills are clearly important, but so are the behaviours that support a patient’s decision making and their confidence in being able to say ‘no’ if they are uncomfortable, in pain and/or anxious. We believe that it is important that RCOG clarifies where this necessary work will be addressed, as a priority. Join the conversation Are you a healthcare worker with insights to share on this topic? Are you a patient who has had a hysteroscopy? Perhaps you are a researcher or have a different perspective to add? You can join the conversation here or get in touch with us directly by emailing content@pslhub.org References Campaign Against Painful Hysteroscopy, Open letter to the Department of Health and Social Care, 20 October 2020 Dr Richard Harrison, “Pain-free hysteroscopy”, 6 November 2020 Patient Safety Learning, Through the hysteroscope: Reflections of a gynaecologist, 26 January 2021 Patient Safety Learning, Improving hysteroscopy safety, November 2020 Patient Safety Learning, Minister acknowledges patients’ concerns about painful hysteroscopies; but will action be taken?, 20 January 2021 Patient Safety Learning, Ministers respond to patients’ concerns about painful hysteroscopies: Northern Ireland, Scotland and Wales, 15 February 2021 RCOG, Good Practice Paper: Pain relief and informed decision-making for outpatient hysteroscopy and procedures, February-March 2022 Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019 Patient Information Forum, PIF TICK, Last Accessed 15 March 2022- Posted
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What is an Adjournment Debate? There is a 30 minute Adjournment Debate at the end of each day's sitting of the House of Commons. They provide an opportunity for an individual backbench MP to raise an issue and receive a response from the relevant Minister. Unlike many other debates, these take place without a question which the House of Commons must then make a decision on. NHS Hysteroscopy Treatment In this debate Lyn Brown MP outlined the issue of significant numbers of women who experience extreme levels of pain when undergoing hysteroscopy, highlighted by groups such as the Campaign Against Painful Hysteroscopy. She shared several patient testimonies, highlighted concerns about healthcare professionals dismissing and ignoring patients concerns and emphasised the need for NHS trusts to offer patients who need a hysteroscopy a full range of anaesthetics and to inform them accurately about the risk factors for serious pain. You can read the full transcript of the debate here. Join the conversation Are you a patient who has had a hysteroscopy? You can share your experience with us, and read those of others, here. Related Reading Campaign Against Painful Hysteroscopy: patient stories, September 2018 Patient Safety Learning, Improving hysteroscopy safety, 6 November 2020 Patient Safety Learning, Minister acknowledges patients’ concerns about painful hysteroscopies; but will action be taken?, 20 January 2021 Patient Safety Learning, Ministers respond to patients’ concerns about painful hysteroscopies: Northern Ireland, Scotland and Wales, 15 February 2021 Patient Safety Learning, Through the hysteroscope: Reflections of a gynaecologist, 26 January 2021 Richard Harrison, “Pain-free hysteroscopy”, a blog by Dr Richard Harrison, 6 November 2020- Posted
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Woman’s Hour: Hysteroscopy (June 2019)
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Painful hysteroscopy and biopsy (November 2019)
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Patients, campaign groups and politicians have raised serious safety concerns around outpatient hysteroscopy for several years, arguing that women are suffering avoidably. Some women have described how the lack of forewarning, coupled with the trauma of the experience itself, left them feeling that both their body and trust had been violated. Many received little or no pain relief and were not given the information needed to make an informed choice about their own care and their own bodies. Those voices need to be heard and hysteroscopy processes reviewed accordingly to ensure the safest delivery of care, reflective of lived experience. Helen Hughes, Chief Executive of Patient Safety Learning, says: “There are clear diagnostic benefits of having a hysteroscopy, and a small number of women may not feel any pain. This is not, however, a good enough reason to dismiss the significant number of women who have reported unbearable levels of pain when undergoing the procedure as an outpatient. These experiences warrant urgent attention if future harm is to be prevented.” Patient Safety Learning supports the call for: National guidance for outpatient hysteroscopy to be consistently applied Women to be provided with information and advice to inform their consent Women to be offered and provided with pain relief Significant pain to be considered an adverse event and recorded and reported as such Research to assess the scale of unsafe care and pain, the extent to which women are suffering, the implementation of national guidelines and the appropriateness of financial incentives without proper safeguards. Baroness Cumberlege reported in her recent review[2] that patients “should not have to join the dots of patient safety”. Patient Safety Learning considers that this is another example where women’s rights to safe services are being compromised, and seeks an urgent response from healthcare leaders to address this significant patient safety issue. Pain during hysteroscopy Recent research, published in the British Journal of Anaesthesia, shows that 17.6% of women rate their pain during hysteroscopy as greater than 7/10, and only 7.8% report no pain at all[3]. Another study estimates the number of women reporting intense or intolerable pain to be much higher at around 25%.[4] This data is supported by the countless testimonials from women who say they have been left feeling in shock, violated and traumatised following very high levels of pain.[5] “I began to hyperventilate with the pain, I was sweating and shaking and I believe I had gone into shock.”[6] Despite the evidence that women can experience unbearable pain, in surveying patients, the Campaign Against Painful Hysteroscopy (CAPH) found that the risk of significant pain is very rarely communicated to women beforehand. Instead, the advice given is usually to take over the counter painkillers and that any discomfort should be minimal. “I was reassured that for most women it is just like period pain and just asked to take paracetamol. Three hours later I found myself screaming from my guts, to stop! Please stop!”[7] Is there informed consent? The principle of consent is an important part of medical ethics and international human rights law. Failure to obtain informed consent can lead to avoidable patient harm, as highlighted by Nadine Montgomery’s story.[8] This led to a landmark ruling, stating that doctors must ensure patients are aware of any risks involved in a proposed treatment, and of reasonable alternatives. The NHS defines informed consent as: The person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead. There are a growing number of women who were not given sufficient information and therefore do not feel they gave informed consent before their hysteroscopy procedure. Many were not told about the risk of high levels of pain or given an opportunity to discuss the pros and cons of all the available options (such as general anaesthetic or sedation). “I am a midwife myself and spoke to the consultant explaining how anxious I felt regarding the procedure, as I had had a very painful / difficult removal of Mirena coil previously and been told I had a cervical stenosis. I asked could I have sedation and was declined saying it would only be ‘brief discomfort’ and to just take painkillers a couple of hours before”.[9] Speaking to the House of Commons in September, Lyn Brown MP, called for urgent action to improve hysteroscopy processes and patient safety, highlighting the fact that this issue had been brought to Parliament eight times in total. In her statement, she read aloud the words of patients, illustrating the physical and psychological trauma experienced by many and the impact of not being fully informed. One account came from Rebecca, who was given no information before her appointment, received no warnings about severe pain and was not offered sedation. “The procedure seemed to go on and on. It was barbaric and, as I hadn’t been given any warning, I felt panicked and unsafe.”[10] The CAPH has surveyed many women who have reported experiences to similar Rebecca’s.[11] Particularly alarming is that we are also hearing of women whose procedures were not paused to re-obtain consent, despite clear expressions of distress and extreme pain. The responses collected by the CAPH and patient forums[12] also highlight the damaging impact that these traumatic experiences can have on a patient’s relationship with the healthcare system. A lack of forewarning of the risks, or information about the choices available, have left some mistrustful and fearful of accessing healthcare services again. Many have described feeling violated. Some have reported long-lasting trauma and have been diagnosed with Post Traumatic Stress Disorder (PTSD). “I would dream that I was back in hospital having the procedure and racked with pain. Some nights I would wake up screaming, sweating and with my heart racing. Then, during the day, I started getting flashbacks of the examination.” [13] Listening to and engaging with patients There is clearly a huge disconnect between the information given beforehand and the actual lived experience of many women who have an outpatient hysteroscopy. Research indicates there is also a substantial disconnect between patient and clinician understanding of the pain experienced during the procedure, and that clinician perception of a patient’s pain during hysteroscopy is not a reliable assessment method. [14] Listening to patients is therefore vital to understanding what is happening and how these gaps can be bridged to prevent future harm. The CAPH has been challenging the processes around hysteroscopy procedures for several years. They have engaged with hundreds of patients to understand the extent of the issue and to identify common themes. In October they wrote to Matt Hancock MP, Secretary of State for Health and Social Care and Nadine Dorries MP, Minister for Patient Safety, Suicide Prevention and Mental Health. [15] In their letter, they used both empirical data and the personal stories of women to illustrate the prevalence and seriousness of the issue. Lyn Brown has also retold the stories of women to parliamentary peers, calling for urgent action in response and yet the issues raised have still not been addressed. The Cumberlege Review illustrates the devastating and long-lasting consequences that can occur when patients are not listened to. We know the dismissal of patient voices provides space for harm to persist and causes further psychological distress to those involved. With growing concerns and evidence of harm, it is imperative that hysteroscopy patients are actively encouraged to provide feedback and that they are listened to at all stages of the process. Current guidance The CAPH have been working with the Royal College of Obstetricians and Gynaecologists (RCOG) and others to develop and promote good practice guidance.[16] Collaborative approaches are key to resolving patient safety issues and Patient Safety Learning welcomes and supports this work. However, it is clear that guidance is not being consistently adhered to, leaving women susceptible to alarmingly varied standards of hysteroscopy care. This raises important questions. Why are good practice guidelines that already exist not being effectively communicated to clinicians and patients, and implemented? How are examples of excellence being shared between clinical colleagues so that all patients can benefit and receive safer care? What are the barriers? Finding the answers to these questions will be key to improving hysteroscopy processes for all women. Currently, the NHS Best Practice Tariff financially incentivises hysteroscopy procedures being performed under outpatient services. Patient Safety Learning believes this framework has created unintended consequence of avoidable harm and requires urgent review. The safety of patients must be prioritised.[17] Responding to concerns about this in a recent House of Commons debate, Nadine Dorries indicated that NHS England and NHS Improvement will shortly be looking at policy proposals for the 2021-22 national tariff, which would remove this incentive.[18] What action is needed? So, if we know that there is a significant problem, why is it not being addressed? Why are NHS leaders not listening to women, to MPs or to clinicians? Why have effective clinical procedures not been applied safely to thousands of women over many years? Patient Safety Learning believes that the reasons for this are well reflected in the Cumberledge Review. We eagerly await the government’s response to its recommendations, but we must act urgently to address painful hysteroscopies. Both the CAPH and Lyn Brown have made several recommendations to the government for improving hysteroscopy processes.[19-20] Recently, pain researcher and co-author of Pain-free day surgery? Evaluating pain and pain assessment during hysteroscopy, Dr Richard Harrison, has highlighted his own concerns: "The dangers of advertising hysteroscopy as a mildly painful procedure are many. Firstly, this stands to put women off engaging with a very useful diagnostic test for the identification of serious medical conditions, such as ovarian cancer or endometriosis. But secondly, it is highly plausible that the resulting prediction error stands to make the experience even more painful than if patients were appropriately warned."[21] On social media, clinicians are also questioning why women are not warned of the risk of pain involved in gynaecological procedures, and why medical education describes these procedures as being only mildly discomforting for women.[22] This touches on a much wider debate around gender pain bias in healthcare[23]. Drawing on all these insights and recommendations, Patient Safety Learning believes that we need to consider the following: Designing and delivering for patient safety o National guidance for outpatient hysteroscopy should be consistently applied o There should be a clear requirement to prevent unsafe care and painful hysteroscopies; this should be embedded in commissioning guidance o There should be the removal of perverse financial incentives o Women should be offered and provided with pain relief o Patient feedback needs to be routinely collected and made publicly available in order to inform the delivery of safer care and respond appropriately in the event of harm o Significant pain should be considered an adverse event, being recorded, reported and responded to appropriately o Research should be undertaken to assess the scale of unsafe care and pain, the extent to which women are suffering, the implementation of national guidelines and the appropriateness of financial incentives and proper safeguards. Patient information, advice, and consent o Patient information should include the risk of severe pain and the clinical factors that may make someone more susceptible (see RCOG patient leaflet developed with CAPH)[24] o Patients should be made aware of all available choices for pain management and supported in weighing up the risks and benefits o It must be clearly communicated to patients that they can stop the procedure at any point o Patients should be encouraged to bring someone with them in case they require physical or psychological support following the procedure. Staff competence and training o Only trained staff should undertake hysteroscopies o Hysteroscopy staff should receive standardised and regulated training. This should include the risks of severe pain, clinical factors that make someone more susceptible, the limitations of clinician perception to assess pain, the importance of listening to women throughout and the application of consent guidelines. How can you help? From patients to politicians, clinicians to researchers, charities to campaigners, there are many people who are working tirelessly to improve hysteroscopy processes. Patient Safety Learning want to help ‘join the dots’ and bring those insights together to work towards safer care. We will support and promote this work, using our influence to promote the action that is needed. Raise awareness We would encourage readers to share this blog widely on social media platforms to help raise awareness of the safety issues surrounding hysteroscopy and to add weight and urgency to the call for action. #share4safety The content of this blog or the CAPH open letter can also be used as a letter template for anyone wishing to call for action from their local MP. They also provide a useful briefing tool, that can be used to inform journalists, decision makers and clinical leaders of the situation. You can find out how to contact your MP here. Join the conversation Are you a healthcare worker with insights to share on this topic? Are you a patient who has had a hysteroscopy? Perhaps you are a researcher or have a different perspective to add? We are capturing insights and suggestions for action on a new area of the hub, our free learning platform for patient safety. You can join the conversation here or get in touch with us directly by emailing content@pslhub.org. Stay connected Join the Patient Safety Learning community and sign up to the hub for free. As a member, you’ll be able to join the conversation, get early access to events and receive regular news and updates about patient and staff safety. Follow us on: Twitter @ptsafetylearn Facebook Patient Safety Learning LinkedIn Patient Safety Learning References [1] NHS England and NHS Improvement, 2019/20 National Tariff Payment System – A consultation notice: Annex DtD Guidance on best practice tariffs, (2019). [2] Baroness Cumberlege, J. The Independent Medicines and Medical Devices Review. 2020. [3] Harrison, R, Kuteesa, W, Kapila, A. Pain-free day surgery? Evaluating pain and pain assessment during hysteroscopy. Journal of Anaesthesia. 2020. [4] Jansen FW, Vredevoogd, CB, Van Ulzen K, et al. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. 2000; 96: 266-270. [5] Campaign Against Painful Hysteroscopy: Patient Stories. 2018. [6] Care Opinion forum, Painful Hysteroscopy. 2017. [7] Erminia. "I didn't sleep for 5 nights after this happened". Care Opinion 2018. [8] Montgomery N. Nadine’s Story: Consent. NHS Resolution 2019. [9] Campaign Against Painful Hysteroscopy. Open Letter to Matt Hancock MP and Nadine Dorries MP. [10] Hansard, House of Commons, NHS Hysteroscopy Treatment. 2020. [11] Campaign Against Painful Hysteroscopy: Patient Stories,. 2018. [12] Patient Safety Learning’s the hub, Community Forum, Painful Hysteroscopy. 2020. [13] Daily Mail, Grandmother-of-three, 67, was left with PTSD after routine NHS medical check caused pain worse than childbirth... and she’s one of thousands of women. 2020. [14] Harrison, R, Kuteesa, W, Kapila, A. Pain-free day surgery? Evaluating pain and pain assessment during hysteroscopy. Journal of Anaesthesia. 2020. [15] Campaign Against Painful Hysteroscopy. Open Letter to Matt Hancock MP and Nadine Dorries MP. [16] Royal College of Obstetricians and Gynaecologists, Outpatient Hysteroscopy. 2018. [17] NHS England and NHS Improvement, 2019/20 National Tariff Payment System – A consultation notice: Annex DtD Guidance on best practice tariffs. 2019. [18] Hansard, House of Commons, NHS Hysteroscopy Treatment. 2020. [19] Campaign Against Painful Hysteroscopy. Open Letter to Matt Hancock MP and Nadine Dorries MP. 2020. [20] Hansard. NHS Hysteroscopy Treatment. House of Commons 2020. [21] Harrison, R. "Pain-free hysteroscopy". Richard Harrison's website. 2020. [22] Twitter thread [23] Billick J. Pain Bias: The health inequality rarely discussed. BBC Future. 2018. [24] Royal College of Obstetricians and Gynaecologists, Outpatient Hysteroscopy. 2018.- Posted
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