Ms L complained that the Health Board failed to take timely and appropriate action to investigate her persistent diarrhoea and rectal bleeding in 2021, and then to identify and diagnose her colon cancer following her GP’s urgent referral in February 2023.
The investigation found that, whilst a colonoscopy in 2021 did not identify any disease in Ms L’s bowel, there is a recognised “miss rate” which means that disease can be missed through no fault of the procedure or the clinician conducting it. Ms L’s cancer had probably developed from a polyp that was missed in the original 2021 colonoscopy. There were failures to consider this possibility and repeat that procedure, as well as a lack of appropriate proactive investigation to find the cause of Ms L’s ongoing symptoms. There were also lengthy delays confirming test results and arranging follow-up appointments. These failings and delays meant that the opportunity to remove this polyp, and therefore either prevent Ms L’s cancer from developing or identify it when it was easier to treat, was lost. Ms L’s treatment included 2 life changing surgeries, chemotherapy and radiotherapy, and the whole situation had a serious impact on her physically, mentally and financially. This was a significant injustice to Ms L. Accordingly, the complaint was upheld.
The Health Board agreed to apologise to Ms L for the failings identified and offered her £4,000 in recognition of the serious consequences. It also agreed to remind relevant clinicians of the recognised “miss rate” in colonoscopies and the importance of fully investigating ongoing symptoms even if a colonoscopy is clear. The Health Board also agreed to review the waiting list for surveillance colonoscopies to identify any patients waiting with an urgent clinical need and to offer them an appointment. Finally, it agreed to confirm that the relevant doctor in this case reflected on the findings of the Ombudsman’s report at his next annual appraisal.