Decision Report 201401794

Summary

Mrs C was scheduled to undergo a flexible sigmoidoscopy (a procedure whereby the rectum is examined by a camera). She had experienced pain during a similar procedure in the past and said that she requested sedation. Mrs C complained that, when the surgeon arrived, he advised that she would not require sedation and started the procedure. Mrs C experienced pain during the procedure and asked for sedation, however, the surgeon carried on. Mrs C was subsequently diagnosed with a perforated bowel. She complained that her requests for sedation before and during the procedure were ignored. Mrs C also complained that the board failed to answer points raised in her formal complaint regarding the procedure.

We took independent medical advice from a consultant general and colorectal surgeon. We found that Mrs C's records indicated she consented to the procedure commencing without sedation, so we did not uphold this aspect of her complaint. However, her care plan noted that she may require sedation during such a procedure so we were critical of the board, as the surgeon proceeded with the procedure despite Mrs C's discomfort and requests for sedation. This went against pre-operative advice given to patients that they can ask for the procedure to be halted at any time and request sedation. We concluded that the surgeon proceeded based on what he considered was best for Mrs C, rather than taking her own views into account.

Whilst we were satisfied that the board responded to the questions that Mrs C raised in her complaint, we considered that the response failed to demonstrate that her core concerns had been taken on board and appropriate action taken to avoid similar problems for other patients.

Recommendations

We recommended that the board:

• bring the failings our investigation has found to the attention of the surgeon for reflection as part of his next annual appraisal;
• remind relevant surgical staff of the contents of the patient leaflet, including that the patient may request sedation at any point; and
• issue Mrs C with an apology, acknowledging that it was not acceptable for the surgeon to override her request for sedation.