NHS England
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NHS England has issued a reminder of national guidance on alternative investigations for patients unsuitable for colonoscopy and will include an update at a national network meeting. Regionally, the ICB will review criteria for deeming patients to have declined treatment and establish mitigations.
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Dear Ms Combes, Re: Regulation 28 Report to Prevent Future Deaths – Marie Bell who died on 29th July 2025. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8th July 2026 concerning the death of Marie Bell on 29th July 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Marie’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Marie’s care have been listened to and reflected upon. Your Report raised concerns that alternative screening tests were not offered when Marie was unable to tolerate the planned colonoscopy procedure due to her comorbidities. This was then incorrectly marked as her having declined the test. NHS England can confirm that there is existing published national guidance which sets out the Bowel Cancer Screening pathway requirements which includes actions required regarding colonoscopy or other diagnostic tests. The guidance stipulates that ‘screening centres must have systems in place to:
• Provide clinic appointments with Specialist Screening Practitioners (SSP) who are trained in accordance with Specialist Screening Practitioners education and training requirements to assess fitness for colonoscopy (or other diagnostic tests) and discuss the procedure.
• Make sure individuals offered colonoscopy are fully aware of what the procedure entails (including possible benefits and risks), and accurately document their consent.
• Undertake screening colonoscopies in line with programme guidelines on colonoscopy, using screen accredited colonoscopists (guidance on accreditation is available from the Bowel Cancer Screening Accreditation (BCSA) website.
• Offer computed tomographic colonography (CTC) where an individual is medically unsuitable for colonoscopy.
• Contact patients the day after colonoscopy to check there are no complications following the procedure and to confirm when to expect results’
[Page 2] There is also published national guidance which covers the scenarios of individuals being unfit for colonoscopy and where there is an incomplete colonoscopy. The guidance states as follows: ‘2. Patients unfit for colonoscopy For patients with significant comorbidities the risks of colonoscopy may outweigh the benefits. In these situations, a clinical decision should be made by a BCSP accredited colonoscopist in conjunction with the patient, to discuss if any screening intervention is appropriate. In cases where a patient is unfit for colonoscopy and the clinical condition will not improve, the patient can be ceased from screening following discussion with the patient. This should be documented within the patient’s episode notes on the bowel screening IT system (BCSS) (refer to Bowel Cancer Screening Consent and Ceasing Guidance). Some patients who are currently unfit for colonoscopy may have a condition that is likely to clinically improve or be on medication such as anticoagulants that should not be stopped for a diagnostic procedure. In these situations, a clinical decision should be made referring to relevant guidance (e.g. BSG and ESGE anticoagulation guidance 2021) as well as seeking external advice from specialist clinicians if appropriate (e.g. haematologist/cardiologists/alcohol liaison teams) to assess suitability for colonoscopy. Options should then be discussed with the patient on when and how to proceed. All patients on anticoagulants alone with a history of prior coronary stents must be either switched to aspirin or discussed with an interventional cardiology consultant first (refer to Addendum to BSG anticoagulation guidance issues 3 June 2024). Alternative options may include:
• A computed tomography colonoscopy (CTC) for those that meet the criteria for a colonoscopy but who are assessed as medically unfit for the procedure (refer to BCSP Guidelines for CTC Imaging). This includes those with complex, severe co-morbidities, with medication or mobility needs making the risks or difficulties of colonoscopy unacceptable, those with significant neurological, cardiovascular or respiratory co-morbidities which might compromise the safety of the procedure and those that are deemed too frail to undergo standard laxative bowel preparation.
• A diagnostic colonoscopy.
• Or to delay the colonoscopy. A subsequent plan for management of any pathology identified must be agreed with the patient. These decisions must be documented and episode notes entered onto BCSS to ensure that all reports and alerts are acted upon to ensure timely progression and closure of a patient episode. Under the Equality Act 2010, screening providers have a legal duty to make reasonable adjustments to make sure services are accessible to people with learning
[Page 3] and physical disabilities. NHS bowel cancer screening: identifying and reducing inequalities provides more information on identifying and reducing inequalities.’ ‘4. Colonoscopy procedure In the case of an incomplete colonoscopy, it is at the discretion of the BCSP accredited colonoscopist to request a repeat procedure, possibly by an alternative BCSP accredited colonoscopist or with an alternative bowel preparation, or to request a BCSP computed tomography colonoscopy (CTC)’. In line with published guidance, where one means of investigation is not suitable for an individual due to comorbidities, we would expect a clinical discussion to have taken place and be documented regarding next steps, rather than there being an assumption the individual has declined all investigations without exploring alternatives. The National Bowel Cancer Screening programme team at NHS England will work with local services to ensure the published national guidance is understood and implemented. A message was sent from the screening quality assurance service as a reminder of the guidance in July and an update will be included at the next national colonoscopy network meeting in Quarter 3 of 2026/27. Regional Response North East and Yorkshire regional colleagues have advised that North East and North Cumbria Integrated Care Board (ICB) will ask the Trust for a review of their criteria for patients referred for Faecal Immunochemical Tests (FIT) but who are unable to undergo a colonoscopy. They will establish the criteria for when deeming a patient to have ‘declined’ treatment, what their mitigations are and whether they have consultant oversight. The ICB have advised that they will use the learning from this Report to highlight this as a system risk. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Marie, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
• Provide clinic appointments with Specialist Screening Practitioners (SSP) who are trained in accordance with Specialist Screening Practitioners education and training requirements to assess fitness for colonoscopy (or other diagnostic tests) and discuss the procedure.
• Make sure individuals offered colonoscopy are fully aware of what the procedure entails (including possible benefits and risks), and accurately document their consent.
• Undertake screening colonoscopies in line with programme guidelines on colonoscopy, using screen accredited colonoscopists (guidance on accreditation is available from the Bowel Cancer Screening Accreditation (BCSA) website.
• Offer computed tomographic colonography (CTC) where an individual is medically unsuitable for colonoscopy.
• Contact patients the day after colonoscopy to check there are no complications following the procedure and to confirm when to expect results’
[Page 2] There is also published national guidance which covers the scenarios of individuals being unfit for colonoscopy and where there is an incomplete colonoscopy. The guidance states as follows: ‘2. Patients unfit for colonoscopy For patients with significant comorbidities the risks of colonoscopy may outweigh the benefits. In these situations, a clinical decision should be made by a BCSP accredited colonoscopist in conjunction with the patient, to discuss if any screening intervention is appropriate. In cases where a patient is unfit for colonoscopy and the clinical condition will not improve, the patient can be ceased from screening following discussion with the patient. This should be documented within the patient’s episode notes on the bowel screening IT system (BCSS) (refer to Bowel Cancer Screening Consent and Ceasing Guidance). Some patients who are currently unfit for colonoscopy may have a condition that is likely to clinically improve or be on medication such as anticoagulants that should not be stopped for a diagnostic procedure. In these situations, a clinical decision should be made referring to relevant guidance (e.g. BSG and ESGE anticoagulation guidance 2021) as well as seeking external advice from specialist clinicians if appropriate (e.g. haematologist/cardiologists/alcohol liaison teams) to assess suitability for colonoscopy. Options should then be discussed with the patient on when and how to proceed. All patients on anticoagulants alone with a history of prior coronary stents must be either switched to aspirin or discussed with an interventional cardiology consultant first (refer to Addendum to BSG anticoagulation guidance issues 3 June 2024). Alternative options may include:
• A computed tomography colonoscopy (CTC) for those that meet the criteria for a colonoscopy but who are assessed as medically unfit for the procedure (refer to BCSP Guidelines for CTC Imaging). This includes those with complex, severe co-morbidities, with medication or mobility needs making the risks or difficulties of colonoscopy unacceptable, those with significant neurological, cardiovascular or respiratory co-morbidities which might compromise the safety of the procedure and those that are deemed too frail to undergo standard laxative bowel preparation.
• A diagnostic colonoscopy.
• Or to delay the colonoscopy. A subsequent plan for management of any pathology identified must be agreed with the patient. These decisions must be documented and episode notes entered onto BCSS to ensure that all reports and alerts are acted upon to ensure timely progression and closure of a patient episode. Under the Equality Act 2010, screening providers have a legal duty to make reasonable adjustments to make sure services are accessible to people with learning
[Page 3] and physical disabilities. NHS bowel cancer screening: identifying and reducing inequalities provides more information on identifying and reducing inequalities.’ ‘4. Colonoscopy procedure In the case of an incomplete colonoscopy, it is at the discretion of the BCSP accredited colonoscopist to request a repeat procedure, possibly by an alternative BCSP accredited colonoscopist or with an alternative bowel preparation, or to request a BCSP computed tomography colonoscopy (CTC)’. In line with published guidance, where one means of investigation is not suitable for an individual due to comorbidities, we would expect a clinical discussion to have taken place and be documented regarding next steps, rather than there being an assumption the individual has declined all investigations without exploring alternatives. The National Bowel Cancer Screening programme team at NHS England will work with local services to ensure the published national guidance is understood and implemented. A message was sent from the screening quality assurance service as a reminder of the guidance in July and an update will be included at the next national colonoscopy network meeting in Quarter 3 of 2026/27. Regional Response North East and Yorkshire regional colleagues have advised that North East and North Cumbria Integrated Care Board (ICB) will ask the Trust for a review of their criteria for patients referred for Faecal Immunochemical Tests (FIT) but who are unable to undergo a colonoscopy. They will establish the criteria for when deeming a patient to have ‘declined’ treatment, what their mitigations are and whether they have consultant oversight. The ICB have advised that they will use the learning from this Report to highlight this as a system risk. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Marie, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.