Decision report 201104091

Summary

Ms C's medical practice referred her to a consultant surgeon at the hospital because she had rectal bleeding and loose stools. Tests were carried out and an inital diagnosis of proctitis (the mildest form of colitis, which is inflammation affecting the lining of the bowel causing diarrhoea and rectal bleeding).

As Ms C's symptoms did not improve with the medication that she was prescribed, she was referred to a consultant gastroenterologist (a medical professional specialising in the treatment of conditions affecting the liver, intestine and pancreas). Ms C attended several clinic appointments between March 2010 and June 2011 and had various investigative procedures carried out in response to her ongoing symptoms of fatigue and passing blood. Ms C's condition worsened in October 2011 and she was admitted to a different hospital where she underwent an emergency colectomy (an operation to remove the large bowel).

Ms C complained that the consultant gastroenterologist had failed to diagnose the severity of her condition. She felt that earlier diagnosis would have allowed alternative drug therapy to be tried which might have avoided the need for the colectomy and a stoma (a surgically made pouch on the outside of the body). Ms C was unhappy that the consultant gastroenterologist had not clearly told her that she had ulcerative colitis and that he had said at an appointment in June 2011 that there was nothing seriously wrong.

We did not uphold Ms C's complaint. After taking independent advice from one of our medical advisers, we found that Ms C was correctly referred to the consultant gastroenterologist and reviewed with a frequency appropriate to her condition and symptoms. In addition, Ms C was prescribed appropriate medication although it was identified that she had an intolerance to one of the drugs. Our adviser explained that flare-ups in ulcerative colitis can happen unpredictably and that Ms C's severe episode that led to the colectomy could not have been predicted or prevented. We found evidence that the consultant gastroenterologist clearly explained at an early stage the results of the investigative procedures and Ms C's diagnosis. However, we could not say exactly how much information they shared with Ms C about her condition, as there was a lack of documented information about this. Although we did not uphold Ms C's complaint, we drew the board's attention to the lack of information and to the relevant guidance about keeping records.