Decision Report 202203018

Summary

C, an advocate to A, complained on behalf of A that their colonoscopy was performed without sedation or anaesthetic. A was advised at pre-assessment that they could not have pain relief during the procedure, due to having taken methadone prior to the colonoscopy. C also complained about the lack of information on the patient leaflet for methadone users, the attitude of staff, and that the procedure was performed by a trainee endoscopist.

The board considered that the care and treatment provided to A was reasonable as A consented to the colonoscopy being carried out without pain relief and understood that a trainee would undertake the procedure. The board apologised for the comments made by staff.

We took independent advice from a colorectal surgeon. We found it unnecessary to contain methadone specific information on the patient leaflet as all medication should be considered when administering sedation for all patients. We found that the advice given at pre-assessment was incorrect. There is no contraindication (a specific situation in which a medicine, procedure, or surgery should not be used because it may be harmful to the person) for use of sedation with methadone and being on methadone does not preclude either sedative or opioid pain control. Therefore, we found that A should have been given pain relief during the colonoscopy. We also found that it is the endoscopist's responsibility to understand drug interaction in prescribing medication for pain and sedation and that was not the case in this instance and a second opinion should have been sought. Due to the absence of pain relief, we found that this procedure should have been performed by an experienced endoscopist, to ensure correct technique and minimise the discomfort experienced by A. As such, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• All staff are familiar with the relevant BNF and AOMRC guidance.
• All staff are reminded of the importance of seeking specialist advice in complex or unusual cases.
• Endoscopists to be aware of the importance of technique when minimising discomfort for the patient.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.