Decision report 201100264

Summary
Ms C was admitted to hospital after a colonoscopy to remove a polyp from her bowel. She was discharged and a further diagnostic appointment was made for some months later. A flexible sigmoidoscopy was to be carried out at that appointment to check for other polyps, and she was advised to take laxatives before attending, to reduce faecal matter. At the appointment, however, she was told that the procedure could not be fully completed due to 'faecal loading'. Ms C was told that she would have to wait 12 months for another appointment. She complained about the nursing care that she received during her stay in hospital and that there was confusion prior to her diagnostic appointment as to what procedure she had been booked for. She also complained that she was prescribed insufficient laxatives, that her procedure was unnecessarily delayed and that the board proposed insufficient follow-up action.

We found the nursing care during Ms C's initial hospital admission to be poor. Her fluid intake was not properly monitored and failed attempts were made to catheterise her, causing her discomfort, when there was no clinical need for this. Although Ms C was given incorrect verbal information about the further procedure, we found that the correct procedure had in fact been booked. The board confirmed that the procedure was delayed, but we were satisfied with their explanation that this was due to the urgent clinical needs of other patients.

We found the prescription of laxatives to be appropriate and, whilst faecal loading prevented a full inspection of the colon, our medical adviser confirmed that the consultant was able to see enough to confirm that no further sinister polyps were present. As such, further review in 12 months was considered appropriate, although the board did not explain this clearly to Ms C.

Recommendations
We recommended that the board:
• use this complaint to remind staff of the importance of accurate recording in records including recording of dignity issues; and
• apologise to Ms C for the failings identified regarding record-keeping, catheterisation, and the fact that their initial response to her complaint did not adequately address concerns about the outcome of her sigmoidoscopy.