16. When we look to determine if there was a failing in the care and treatment complained about, we first consider what should have happened in line with relevant policies, guidelines, standards, and good clinical practice. We then use all available evidence to determine if what should have happened, did happen. If it did not, we then consider if what did happen fell so far short of what should have happened that it amounts to a failing.
17. Miss P told us the Trust conducted a colonoscopy on 15 May 2022, in which it found and removed a polyp. Following this, her abdominal pain symptoms continued. Miss P said the Trust said as there was no diagnosis for her symptoms, it was unable to refer her to a specialist.
18. Miss P says the Trust informed her the colonoscopy result was normal. She says she was still in constant pain, and as the Trust confirmed it was difficult to know who to refer her to due to a lack of diagnosis, she took her care to Hospital B. We are sorry to learn of Miss P’s experience.
19. The records show Hospital B subsequently identified and removed two further polyps in November 2022. Miss P says the option to have a second opinion is a fundamental right, and she felt condemned to be in pain or the rest of her life whilst under the care of the Trust.
20. The Trust explained in its response letter it did take Miss P’s symptoms and concerns seriously, and it took appropriate steps to address them. The Trust apologised for Miss P not being confident in continuing her care at the Trust and giving it the opportunity to undertake further investigations.
21. Our adviser said they are two possible scenarios regarding the Trust potentially missing the two polyps Hospital B later found and removed. The polyps could have grown in the six months between May and November 2022, or the poylps were there and were not identified by the Trust in May 2022. Our adviser agreed it is likely they were missed by the Trust.
22. Our adviser says is important to note the symptoms following the colonoscopy were like not as a result of the the polyps, as the polyps were completely asymptomatic, and an incidental finding on the colonoscopy. This is because:
• they were very small in size. For a polyp to cause pain, it would have to be of a certain size to block the lumen (opening of the bowel). The lumen of the caecum can be 6-8cm in diameter. The caecum is a pouch that forms the first part of the large intestine.
• the location of the polyps in the right colon (a long way from the exit) means that they could not be the cause of fresh rectal bleeding and certainly not bleeding from the vagina
• the location of the polyps also mean they would have no influence on bowel evacuation and their small size would mean that they would have no influence on bowel movement.
23. Our adviser said there is a known and accepted ‘miss rate’ for small polyps of approximately two to three percent. Small polyps can be missed due to poor bowel preparation, where some faeces will cover the polyps. Before a colonoscopy procedure the patient drinks a bowel preparation fluid. This helps clear the bowel, but in some instances some faeces can remain in parts of the bowel.
24. The consequences of missing these small polyps are difficult to determine. It can take five to ten years for some polyps to turn into a cancer. Miss P has a history of previous colonic polyps. Given this, it is likely she would have had another colonoscopy five years after the one done at the Trust. This would likely be an opportunity for the Trust to identify the polyps.
25. The records show the Trust had a telephone consultation with Miss P on 16 June 2022, where it arranged a face to face appointment for 30 June 2022, and agreed to refer Miss P to her original surgeon.
26. We can see Miss P utilised her right to decide which hospital she wanted to receive care from under the NHS choice framework when she decided to move her care to another hospital. Miss P’s medical records show she did not attend follow up face to face appointments following the May 2022 colonoscopy at the Trust. The Trust did not have the opportunity to conduct further investigations to address her symptoms or to form a diagnosis.
27. GMC guidance says,
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
• promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs
28. We thin the Trust acted in line with this guidance by investigating Miss P’s symptoms and arranging assessment by suitable clinicians who knew her medical history.
29. We cannot see evidence of a service failing from the Trust. We have considered the likelihood of the Trust failing to identify the two small polyps. We have looked at what most likely happened, and we think it is more likely the Trust did miss the polyps following the May 2022 colonoscopy procedure. However, we accept that there are reasons for this, and we know there is an acceptable miss rate of two to three percent when conducting a colonoscopy.
30. The Trust made attempts for further follow appointments to investigate Miss P’s symptoms further and agreed to refer Miss P to her original surgeon therefore, we do not feel the service fell so far below the standard for the Trust’s actions to be considered a failing.
31. We recognise Miss P has endured a difficult time and appreciate the distress this experience has caused her. We thank her for bringing her complaint to us and we hope she will find our decision useful in confirming we have not seen any indications that something went wrong with her care.