BEUDAMED
    FDA Adverse Event Injury Summary report: N

    UNK - UNSPECIFIED BY COMPLAINANT

    MDR report key: 3800370 · Received April 3, 2014

    Report

    Report Number
    1835959-2014-00109
    Event Type
    Injury
    Date Received
    April 3, 2014
    Report Date
    April 2, 2014
    Manufacturer
    COOK BIOTECH, INC.
    Product Code
    PAG
    PMA / PMN Number
    UNK
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    DATE OF EVENT NOT PROVIDED BY THE COMPLAINANT. PRODUCT NAME UNK; PRODUCT UNSPECIFIED. PRODUCT COMMON NAME UNK; PRODUCT UNSPECIFIED. LOT NUMBER NOT PROVIDED BY THE COMPLAINANT; PRODUCT EXPIRE DATE UNK; LOT NUMBER NOT PROVIDED; PRODUCT CATALOG NUMBER UNK, PRODUCT UNSPECIFIED. THE 510(K) UNK; PRODUCT UNSPECIFIED. AS REQUESTED BY THE FDA, WE HAVE MADE NOTE OF THE PRODUCT CODE. THE PRODUCT CODE LISTED IS NOT NECESSARILY THE PRODUCT CODE ASSIGNED TO THE DEVICE 510(K), BUT RATHER THE PRODUCT CODE THAT SEEMS THE MOST APPROPRIATE BASED ON THE SURGICAL PROCEDURE IN WHICH THE PRODUCT WAS IMPLANTED. PRODUCT MFR DATE UNK; LOT NUMBER UNK. CONCLUSIONS: ROOT CAUSE INCONCLUSIVE DUE TO LACK OF DETAILS PROVIDED BY THE COMPLAINANT. INVESTIGATION INTO THIS CLAIM INCLUDED A REVIEW OF THE CLAIM ALLEGATIONS AND ALL OTHER COMMUNICATION AND INVESTIGATION INTO THIS REPORT/CLAIM IS BEING HANDLED BY OUR ATTORNEY. BASED ON THE INFO PROVIDED BY THE COMPLAINANT, DETAILS REGARDING A SPECIFIC CORRELATION BETWEEN THE UNSPECIFIED SURGISIS GRAFT'S PERFORMANCE AND THE ALLEGED INJURY REMAIN UNK. A ROOT CAUSE OF THE CLAIMS ALLEGATIONS IS INCONCLUSIVE DUE TO LACK OF DETAILS PROVIDED BY THE COMPLAINANT. ALL OTHER MATTERS RELATING TO THIS LITIGATION ARE BEING HANDLED BY OUR ATTORNEY. IF/WHEN ADD'L INFO IS OBTAINED A FOLLOW-UP MDR WILL BE FILED.

    Description of Event or Problem · 1

    THE PT WAS REPORTEDLY IMPLANTED WITH THE UPHOLD VAGINAL SUPPORT SYSTEM AND THE UNSPECIFIED SURGISIS GRAFT OF (B)(6) 2011, AT (B)(6) MEDICAL CENTER IN (B)(6) BY DR (B)(6), M.D. TO TREAT HER PELVIC ORGAN PROLAPSE AND/OR STRESS URINARY INCONTINENCE. THE PT AND HER ATTORNEY HAVE ALLEGED THAT AS A RESULT OF THIS PRODUCT BEING IMPLANTED IN THE PT, THE PT HAS EXPERIENCED PAIN, INJURY, AND HAS UNDERGONE MEDICAL TREATMENT. THE FOLLOWING INFO WAS NOT PROVIDED BY THE COMPLAINANT: SPECIFIC INFO OF THE ALLEGED INJURY; SPECIFIC INFO REGARDING WHETHER INTERVENTION WAS PERFORMED; SPECIFIC INFO REGARDING WHY INTERVENTION WAS PERFORMED OR WHAT TYPE/TO WHAT EXTENT INTERVENTION WAS PERFORMED; SPECIFIC CORRELATION BETWEEN DEVICE PERFORMANCE AND ALLEGED INJURY; CURRENT PT STATUS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    200330 UNK - UNSPECIFIED BY COMPLAINANT UNK - PRODUCT UNSPECIFIED PAG COOK BIOTECH, INC. NA UNSPECIFIED

    Patients

    Seq Age Sex Outcome Treatment
    1 UNK Disability BOSTON SCIENTIFIC UPHOLD VAGINAL SUPPORT SYSTEM