Decision Report 201508273

Summary

Mrs C complained about the level of pain she experienced during a colonoscopy procedure (an examination of the bowel with a camera on a flexible tube) at Forth Valley Royal Hospital. Mrs C's pain was very bad and the procedure had to be stopped. Mrs C felt that the level of pain that she experienced was caused by failure to give her appropriate sedative and pain medication prior to the procedure. Mrs C highlighted that she had previously undergone the same procedure at another hospital with no ill effects.

After taking independent advice from a consultant colorectal surgeon, we did not uphold Mrs C's complaint. The adviser reviewed the medication that Mrs C received prior to the procedure and confirmed that this was appropriate. The adviser noted that Mrs C had previously had a similar procedure at another hospital and advised that whilst the reasons why this type of investigation can be successful for the same patient on one day but not another are not clear but that is sometimes the case. It was also noted that Mrs C had undergone major abdominal surgery in the past and the adviser explained that adhesions (scar tissue that can make tissues or organs inside the body stick together) can cause pain during colonoscopy procedures.

Although Mrs C's complaint was not upheld, the adviser pointed out that some of the patient information and other guidance did not appear to be current or was due for review, and also that the consent form for the procedure had not been countersigned. We made a number of recommendations to address these issues.

Recommendations

We recommended that the board:

• review their internal guidance and patient information leaflets in relation to colonoscopy procedures to ensure they are current;
• confirm the adviser's comments will be considered during the next review of the pre-procedure patient information leaflet and consent form; and
• take steps to ensure that all endoscopy consent forms are appropriately countersigned.