17. Before we decide if we should carry out a detailed investigation into a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and we have not found any indications that something has gone wrong.
Sigmoidoscopy when Mr K was bleeding
18. Mr K says the nurse who completed the enema before his sigmoidoscopy on 6 November 2020 told him he was bleeding. Mr K complains a surgeon went ahead with the sigmoidoscopy despite the bleeding. Mr K believes the procedure should not have gone ahead due to his bleeding.
19. There is relevant guidance from the British Society of Gastroenterology (BSG). That guidance explains the following are indications for a flexible sigmoidoscopy:
• ‘Investigation of diarrhoea with or without bleeding in acutely ill patients
• Investigation of rectal bleeding in absence of altered bowel habit
• < 40 years with persistent and/or recurrent bleeding with or without change in bowel habit’
20. This tells us rectal bleeding is one of the symptoms which would indicate a flexible sigmoidoscopy was necessary to investigate. Our adviser explained the procedure would have still gone ahead if Mr K had been bleeding. They told us rectal bleeding is not unusual. We understand bleeding is not a reason a sigmoidoscopy should not go ahead.
21. We have carefully reviewed Mr K’s medical records. There is no evidence within the nursing records or the endoscopy records that Mr K bled during the enema.
22. There is also no evidence in the medical records that Mr K was bleeding during any other part of the preparation or procedure itself. We have seen some reference to bleeding in Mr K’s medical records from after the procedure when Mr K told staff about the bleeding.
23. We have seen different evidence relating to whether Mr K was bleeding prior to the procedure. We have taken Mr K’s recollection into account here and we do not discount what he told us about the bleeding.
24. We have come to the view, whether Mr K was bleeding before the procedure or not, it was still in line with guidance for the Trust to proceed. Based on this, there are no indications of failings for this issue, and we should not consider it further.
Sigmoidoscopy caused Mr K to develop a fistula and faecal incontinence
25. Mr K complains the flexible sigmoidoscopy procedure caused him to develop a fistula. He also says the procedure caused him to suffer from faecal incontinence which is still an ongoing condition. It is unfortunate Mr K has suffered those difficult symptoms and we are sorry to hear about his experience.
26. We spoke to Mrs K about the complaint as she is supporting Mr K with it. She told us Mr K had never suffered from faecal incontinence before the procedure took place and that it began the evening of the procedure. She also told us she has seen that a fistula can form as a result of surgery in the colon area.
27. We gained advice from our adviser on this issue. That was to help us understand what the evidence indicates about any connection between the Mr K’s difficult symptoms and the sigmoidoscopy procedure.
28. Our adviser said fistulas and faecal incontinence are not known risks of a flexible sigmoidoscopy. We have seen those complications were not listed on the Trust’s consent form for patients to sign. They are also not included in risks in information from Cancer Research UK. It is also important to note a sigmoidoscopy is not surgery. It is a test using a camera to take images of the bowel.
29. We have also considered information from Macmillan Cancer information and support. It advises bowel cancer is a risk factor which may increase the risk of someone having a fistula. Mr K has previously suffered with bowel cancer.
30. We consider RCS's Good Surgical Practice is relevant to the procedure. A sigmoidoscopy is not surgery, but a surgeon carried out the procedure for Mr K. Section 1.3 on page 6 of that guidance specifically states the record of the procedure should include any problems/complications.
31. Section 3.1.1 on page 9 says 'explain and complications of treatment as they occur and explain the possible solutions'. 1.2.1 also says surgeons should carry out procedures in a safe way.
32. We consider it is more likely than not the Trust would have documented any complications if they occurred, as required by RSC guidance. The medical records indicate the sigmoidoscopy proceeded with no complications. As we have seen in the evidence from our adviser, and the information about a fistula, that condition is not linked to sigmoidoscopy. Incontinence is also not a known risk.
33. As we explained earlier, we have also seen nothing to suggest the sigmoidoscopy was not needed, based on any bleeding Mr K had.
34. We have weighed all the evidence. We consider it indicates, on balance, the symptoms did not occur as a result of the procedure. It therefore seems the Trust carried out the procedure in safe way, in line with the guidance from the RSC.
35. Overall, we can say that on the balance of probabilities, there are no indications of failings for this part of Mr K’s complaint. For this reason, we have decided not to consider it further.
Hospital staff did not identify a fistula around Mr K’s rectum when he was in for six nights
36. Mr K was an inpatient in hospital for six nights from 11 November 2020, following a referral from his GP. This came after Mr K began to experience faecal incontinence. Mr K complains the hospital did not detect the fistula while he was an inpatient.
37. We discussed this issue with our adviser. We understand the most relevant standard here is the GMC Good Medical Practice, 2013. That guidance says doctors must:
‘a. adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient
b. promptly provide or arrange suitable advice, investigations, or treatment where necessary.’
38. We have carefully reviewed Mr K’s medical records provided by the Trust. We have found no reference of the fistula in these records.
39. We found the medical records say a rectal examination took place on 12 November 2020. The notes say the rectum was empty. Our adviser told us a visual examination like this would have been the way staff could identify a fistula. From this evidence we consider it is unlikely there were signs of a fistula at this time.
40. We have seen in the medical records there is evidence the Trust did other tests and investigations for Mr K. These included doctors reviewing him during their rounds. They also included blood tests and X-rays. Our adviser told us these other tests would not have identified the fistula. We have noted there is no mention in the medical records of Mr K being in any pain, such as from a fistula, at the time.
41. The Trust did complete pressure area viewings while Mr K was admitted. However, those did not identify a fistula. Our adviser told us as part of these viewings, nurses would have observed Mr K’s bottom area throughout his stay but would not have done an in depth examination into the area.
42. We have considered all the relevant evidence. We cannot know when the fistula developed or how long Mr K had it for. We have seen in the evidence it does not seem there were signs of the fistula while Mr K was an inpatient. This was despite the Trust’s nurses examining the area in general, and the Trust carrying out the visual examination, which could have identified a fistula.
43. We consider the evidence indicates the Trust adequately assessed Mr K’s condition and examined him where necessary. We have not seen indications Mr K needed further investigations. The evidence indicates the Trust worked in line with the GMC guidance to provide suitable investigations and examinations.
44. Having considered all the evidence, it indicates the Trust provided a good standard of practice and care in line with the GMC guidance. Overall, there are no indications of failings here. We have decided we should not consider this issue further.
45. We are sorry if our decision not to consider Mr K’s complaint further is difficult for him to receive. We are grateful to him for bringing his concerns to our attention.