British Society of Gastroenterology
Other
Noted
The BSG acknowledges the concerns regarding colonoscopies for patients over 80, stating that decisions should be individualised, balancing risks and benefits. (AI summary)
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Dear Mr Appleton Regulation 28 prevention of future death report V J T Nolan Thank you for bringing to our attention the circumstances leading to the death of Vivian Joan Tuddenham Nolan. We understand that she was a patient who underwent a colonoscopy for iron deficiency anaemia and a positive FIT test in March 2025 and sadly died following the procedure. Amongst the medical causes of death was “Colonic Perforation”. The British Society of Gastroenterology (BSG) would like to place on record our condolences to the family of Ms Nolan. We have been asked to address concerns raised during the deceased’s inquest, specifically: -
1. There should be a higher clinical threshold for offering diagnostic colonoscopy to patients over the age of 80 given the associated increased risks;
2. The general lack of awareness amongst clinicians of the potential increased risks of diagnostic colonoscopy in the over 80s age group;
3. There is a higher clinical threshold in other countries. Data provided by the NHS Getting it Right First Time (GIRFT) Model Health System reveals that 5.8% of all colonoscopies performed in England are carried out on those over 80 years of age. Whilst it is accepted that risks associated with any procedure increase with age, all patients should be appropriately consented prior to the procedure being carried out, with any risks, benefits and alternatives to the procedure personalised to the individual patient, taking into account, inter alia, concurrent comorbidities and frailty as well as the age of the patient. The NHS GIRFT Programme National Specialty Report states “Trusts may need to look at whether they are appropriately vetting and pre-assessing colonoscopy referrals, to defer or divert any that are not suitable for colonoscopy. For example, with more frail patients they may want to consider replacing colonoscopy with CTVC or CT…, or to discuss a more conservative approach with these patients.” (1) The British Society of Gastroenterology published guidance on this individualised approach to informed consent in 2023.(2) In April 2025, the BSG also published guidance on the Management of Colorectal Polyps in Patients with Limited Life Expectancy.(3) This document includes careful advice about patient selection for diagnostic colonoscopy.
British Society of Gastroenterology: Company No. 8124892 Charity No. 1149074 / VAT No. 347 4214 61 Specifically, it states: - “…patients with a limited life expectancy should only undergo diagnostic colorectal investigations if the outcome of the investigation has the potential to benefit the patient and that the patient or their representative should be involved in any decision to investigate.” Furthermore: - “…if investigation is deemed appropriate for prognostication in a patient unfit for intervention, to reduce harm from overdiagnosis or overtreatment of irrelevant benign polyps, that CT abdomen/pelvis is undertaken rather than colonoscopy or CT colonography (CTC).” And finally: - “…prior to a diagnostic procedure in all patients with frailty or a limited life expectancy, a clear threshold for therapy is set and discussed with the patient or their representative as part of the informed consent process.” This guidance and that contained in the GIRFT 2021 report reflects the BSG view that thresholds should not be set on the basis of age alone (nor indeed that patients are discriminated against on the basis of their age) but rather should be part of a wide-ranging assessment of the patient. Factors to be considered would include both the strength of the indication for colonoscopy as well as individual patient risk factors. This guidance has been published in Gut, the foremost journal for gastroenterology practitioners and widely publicised to BSG members in newsletters, podcasts and webinars since publication. We have no evidence to suggest that this practice is not being followed nor of evidence to suggest that clinicians are not considering these factors prior to undertaking colonoscopy. The Coroner may be minded to also seek the opinion of the Association of Coloproctology of Great Britain and Northern Ireland (ACPGBI) whose members mainly comprise colorectal surgeons who also carry out colonoscopy, should he consider that raising awareness amongst this group of practitioners would be best served here. We note the suggestion that there is a higher clinical threshold in other countries. Our understanding is that recommendations from other health systems (USA and Europe) are similar to that in the UK in that any decision to undertake a colonoscopy should be individualised to the patient. If you are aware of evidence to the contrary, then we would be happy to review it. Colonoscopy is an important procedure for the investigation and management of gastrointestinal diseases, carrying significant benefits for patients. Whilst the BSG recognises that the risks of any invasive procedure are greater in people who are older, more frail or more comorbid, it is important that the decision to perform a colonoscopy is an informed one, balancing risks and benefits. There is a risk of significant patient harm if the risk of colonoscopy is overstated and not balanced alongside its potential benefits. Therefore, it is essential that these risks and benefits are explained by those who understand them, so that patients are not deterred from undergoing the investigation when it would be in their best interests.
British Society of Gastroenterology: Company No. 8124892 Charity No. 1149074 / VAT No. 347 4214 61 We thank you for bringing this matter to our attention.
1. There should be a higher clinical threshold for offering diagnostic colonoscopy to patients over the age of 80 given the associated increased risks;
2. The general lack of awareness amongst clinicians of the potential increased risks of diagnostic colonoscopy in the over 80s age group;
3. There is a higher clinical threshold in other countries. Data provided by the NHS Getting it Right First Time (GIRFT) Model Health System reveals that 5.8% of all colonoscopies performed in England are carried out on those over 80 years of age. Whilst it is accepted that risks associated with any procedure increase with age, all patients should be appropriately consented prior to the procedure being carried out, with any risks, benefits and alternatives to the procedure personalised to the individual patient, taking into account, inter alia, concurrent comorbidities and frailty as well as the age of the patient. The NHS GIRFT Programme National Specialty Report states “Trusts may need to look at whether they are appropriately vetting and pre-assessing colonoscopy referrals, to defer or divert any that are not suitable for colonoscopy. For example, with more frail patients they may want to consider replacing colonoscopy with CTVC or CT…, or to discuss a more conservative approach with these patients.” (1) The British Society of Gastroenterology published guidance on this individualised approach to informed consent in 2023.(2) In April 2025, the BSG also published guidance on the Management of Colorectal Polyps in Patients with Limited Life Expectancy.(3) This document includes careful advice about patient selection for diagnostic colonoscopy.
British Society of Gastroenterology: Company No. 8124892 Charity No. 1149074 / VAT No. 347 4214 61 Specifically, it states: - “…patients with a limited life expectancy should only undergo diagnostic colorectal investigations if the outcome of the investigation has the potential to benefit the patient and that the patient or their representative should be involved in any decision to investigate.” Furthermore: - “…if investigation is deemed appropriate for prognostication in a patient unfit for intervention, to reduce harm from overdiagnosis or overtreatment of irrelevant benign polyps, that CT abdomen/pelvis is undertaken rather than colonoscopy or CT colonography (CTC).” And finally: - “…prior to a diagnostic procedure in all patients with frailty or a limited life expectancy, a clear threshold for therapy is set and discussed with the patient or their representative as part of the informed consent process.” This guidance and that contained in the GIRFT 2021 report reflects the BSG view that thresholds should not be set on the basis of age alone (nor indeed that patients are discriminated against on the basis of their age) but rather should be part of a wide-ranging assessment of the patient. Factors to be considered would include both the strength of the indication for colonoscopy as well as individual patient risk factors. This guidance has been published in Gut, the foremost journal for gastroenterology practitioners and widely publicised to BSG members in newsletters, podcasts and webinars since publication. We have no evidence to suggest that this practice is not being followed nor of evidence to suggest that clinicians are not considering these factors prior to undertaking colonoscopy. The Coroner may be minded to also seek the opinion of the Association of Coloproctology of Great Britain and Northern Ireland (ACPGBI) whose members mainly comprise colorectal surgeons who also carry out colonoscopy, should he consider that raising awareness amongst this group of practitioners would be best served here. We note the suggestion that there is a higher clinical threshold in other countries. Our understanding is that recommendations from other health systems (USA and Europe) are similar to that in the UK in that any decision to undertake a colonoscopy should be individualised to the patient. If you are aware of evidence to the contrary, then we would be happy to review it. Colonoscopy is an important procedure for the investigation and management of gastrointestinal diseases, carrying significant benefits for patients. Whilst the BSG recognises that the risks of any invasive procedure are greater in people who are older, more frail or more comorbid, it is important that the decision to perform a colonoscopy is an informed one, balancing risks and benefits. There is a risk of significant patient harm if the risk of colonoscopy is overstated and not balanced alongside its potential benefits. Therefore, it is essential that these risks and benefits are explained by those who understand them, so that patients are not deterred from undergoing the investigation when it would be in their best interests.
British Society of Gastroenterology: Company No. 8124892 Charity No. 1149074 / VAT No. 347 4214 61 We thank you for bringing this matter to our attention.