Summary
Mr C complained on behalf of his wife (Mrs A). Mrs A had undergone a colonoscopy (a procedure to examine the inner lining of the large intestine) at University Hospital Crosshouse and, during the procedure, a complication had occurred which caused a perforated bowel. As a result of the perforated bowel, Mrs A had to undergo emergency surgery and she spent time in an intensive care unit. Mrs A required a temporary colostomy (a surgical procedure where an opening is formed in the abdomen). Mr C complained that the colonoscopy was not carried out to a reasonable standard.
We took independent advice from a consultant general and colorectal surgeon. We found that a colonoscopy was the appropriate and recommended procedure in Mrs A's case, taking into account her existing medical conditions. We also found that the doctors involved in the colonoscopy had the relevant experience and were suitably qualified to carry it out. The board said that the perforated bowel was a recognised complication and risk of the colonoscopy. They also said that when the perforation occurred it was quickly recognised and prompt and appropriate action was taken. The board had apologised for the complication that had occurred, and had set out the action they had taken to improve clinical safety.
Taking account of the evidence and the independent advice we received, we did not uphold Mr C's complaint. However, we did ask the board to provide us with evidence of the action they said they had taken, and we made a recommendation to the board with a view to encouraging learning from this complaint.
Recommendations
What we said should change to put things right in future: Where serious incidents occur in colonoscopy procedures, they should be reviewed at least quarterly.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.
Related reading
View Decision Report 201604626 as a PDF (12.52 KB) Updated: March 13, 2018