Summary
Mrs C was scheduled to have a colonoscopy procedure (examination of the bowel with a camera on a flexible tube) at Hairmyres Hospital. It had been planned that Mrs C would be under general anaesthetic. This was because a previous colonoscopy procedure using conscious sedation (to relax and provide pain relief) had been a painful experience for her. However, the operating theatre was unexpectedly unavailable so the procedure was carried out in the endoscopy unit using conscious sedation. Mrs C said that she experienced excessive pain and discomfort during the procedure, and continued to experience pain for more than a month afterwards. Mrs C said that she asked many times for the procedure to be stopped and nursing staff also asked for the procedure to be stopped. However, the doctors (a senior staff grade surgeon and a consultant colorectal surgeon) continued nonetheless. Mrs C said she had been left severely traumatised by what occurred.
As part of my investigation, I obtained independent advice from an adviser who is a consultant colorectal surgeon. Regarding Mrs C's complaint that the colonoscopy procedure went ahead without the general anaesthetic, the adviser said that, as Mrs C had prepared for the procedure and waited a long time that day, it was reasonable for it to be attempted using conscious sedation. However, it should have been clearly understood that if Mrs C experienced excessive discomfort, the procedure should be stopped immediately and rescheduled to be carried out using a general anaesthetic. The adviser considered that the consultant had not complied with General Medical Council guidelines on obtaining informed consent and had communicated with Mrs C poorly. They also found it concerning that these communication failings had not been acknowledged by the consultant or the board.
Mrs C complained that the procedure was carried out without a reasonable level of sedation. The adviser said that the sedation Mrs C received was not enough to provide her with an appropriate level of comfort. As it would have been unsafe to increase the sedation given to Mrs C, the procedure should have been stopped.
Mrs C also complained that the procedure was unreasonably continued despite her requests for it to stop. The adviser said that, in the initial absence of the consultant, it was reasonable for the surgeon to begin the procedure. However, the adviser considered the consultant made a serious error in not giving the surgeon a clear explanation of Mrs C's previous poor experience of colonoscopy and clear instructions to stop if the procedure was too painful or distressing for her. There was evidence in Mrs C's medical records that she and nursing staff asked the surgeon to stop and, in the adviser's view, on arriving to find both patient and nursing staff requesting that the procedure should be stopped, it was unreasonable for the consultant to have taken over and continued. The adviser considered that the evidence clearly demonstrated the withdrawal of Mrs C's consent for the procedure.
I upheld all the complaints. My investigation identified a number of serious failings including poor communication, poor record-keeping, poor understanding of the consent process, and a failure to stop the procedure when asked by Mrs C. I was also concerned that the board and the consultant did not appear to have understood, acknowledged or sufficiently appreciated the seriousness of the failings. Nor had they identified all the learning required or taken sufficient remedial action. I also noted the similarity of the circumstances of another recent complaint (case 201402959) and have taken the recommendations made in that complaint into account in making recommendations in this case.
Redress and recommendations
The Ombudsman recommends that the board:
- and the consultant apologise to Mrs C for the failings identified in this complaint in relation to poor communication and in obtaining informed consent;
- share with the consultant the comments of the adviser in relation to obtaining informed consent from a patient;
- arrange for the consultant, if they have not already done so, to undergo training and a suitable continuing professional development course to improve their communication skills and understanding of the consent process and to provide evidence of this;
- apologise to Mrs C for the failing identified in this complaint in relation to carrying out the procedure without a reasonable level of sedation;
- and the consultant apologise to Mrs C for the failings identified in this complaint in relation to poor communication, a failure to stop the procedure when asked by Mrs C, a poor understanding of the consent process, and poor record-keeping;
- arrange for the consultant and the surgeon to undertake training, if they have not already done so, to improve their communication skills and an understanding of the consent process, particularly where a patient withdraws their consent;
- bring to the attention of the consultant the comments of the adviser to give consideration to submitting a report about what occurred in Mrs C's case to a local morbidity and mortality meeting;
- review the Global Rating Scale (GRS) data from all of their endoscopy units and reflect on the comments of the adviser in relation to achieving good GRS scores;
- provide evidence that all their endoscopy units have standardised documentation for recording of patient discomfort during colonoscopy, in line with recommended practice;
- provide evidence that all their endoscopy units have standardised guidelines for procedural sedation and for withdrawal of consent;
- consider, if they have not already done so, developing guidelines for all their endoscopy units in respect of recommendations (ix) and (x); and submit a synopsis of this case together with current standardised documentation and guidelines to their Endoscopy Governance Group in order to provide dissemination of learning and to minimise variability of colonoscopy practice within their hospitals; and
- provide evidence of the action they say has been taken.