Mrs C complained about the care and treatment she received from the Health Board. The investigation considered whether the decision to remove Mrs C’s polyps (abnormal tissue growths) during a colonoscopy (the examination of the inside of the bowels using a thin tube with a light and camera at the end) performed on 31 July 2022 was clinically appropriate. It also considered whether appropriate treatment was provided to Mrs C following the procedure, in particular when she contacted the Health Board on 3 and 4 August 2022 reporting pain. Finally, the investigation considered whether earlier surgical intervention would likely have prevented Mrs C requiring a colostomy (also referred to as a stoma, where one end of the large intestine is diverted through an opening in the abdominal wall).
The Ombudsman found that the decision to remove Mrs C’s polyps on 31 July was clinically appropriate, and the procedure was carried out to an appropriate standard. That part of the complaint was not upheld. However, the Ombudsman found that appropriate care and treatment was not provided when Mrs C contacted the Health Board to report pain and discomfort following the procedure, as her symptoms should have prompted her re-admission for assessment, so that her peritonitis (a serious infection of the abdominal tissue) and bowel perforation could have been identified sooner. Furthermore, although she may well still have required surgery and colostomy formation if she had been admitted earlier, the likelihood of this would have been reduced. The delay experienced, and the uncertainty caused, was an injustice to Mrs C, as she will never know if the outcome could have been different. The Ombudsman upheld those parts of the complaint.
The Health Board agreed to the Ombudsman’s recommendations that it provide Mrs C with a written apology for the failings identified; to share the investigation report with the relevant endoscopy nurses/Bowel Screening Wales staff, for reflection and learning, regarding telephone availability, returning patient calls and appropriateness of advice given where higher risk procedures have taken place, and; to review its safety netting process for endoscopy procedures, to ensure availability of telephone contacts provided, and consider the introduction of a follow up phone call to patients in the first few days after discharge, where higher risk procedures have taken place.