15. Mrs Y complains that when Mr Y presented to the ED on 8 May 2022, his symptoms were not considered together, and if they had been, he would have had a scan when he presented to the ED. Mrs Y highlights that Mr Y had ongoing abdominal pain, a CRP outside of the normal range, and rectal bleeding.
16. In response to the complaint, the Trust concluded that when considering all the facts of Mr Y’s attendance to the ED, a sigmoidoscopy and/or colonoscopy was the appropriate investigation to request, and there were no indications further immediate investigation was needed at the time.
17. We have reviewed Mr Y’s medical records with our adviser to determine if Mr Y was reviewed appropriately, and if any further investigations were needed at the time of his presentation to the ED.
18. The NICE CKS on the assessment and diagnosis of acute abdominal pain says that clinicians should assess the patient’s vital signs, take a history and ask about the pain (location, onset, duration, severity, progression) and any other symptoms or red flag features, perform an abdominal examination and any other appropriate examinations (such as a rectal examination), and arrange appropriate investigations.
19. The NICE CKS on gastrointestinal tract (lower) cancers says that adults should be referred to a suspected cancer pathway (for an appointment in two weeks) for colorectal cancer if tests show occult blood in their faeces, or they are aged 40 years and over with unexplained weight loss and abdominal pain. A referral should also be considered for adults with a rectal or abdominal mass. Our adviser explained occult blood in the faeces would be blood mixed with the stool, as opposed to fresh blood separate from the stool.
20. The GMC’s Good Medical Practice guidance says doctors must provide a good standard of practice and care, when assessing, diagnosing, or treating patients, they must: • 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, • Promptly provide or arrange suitable advice, investigations, or treatment where necessary, • Refer a patient to another practitioner when this serves the patient’s needs. (point 15)
21. We can see the clinician took a history of Mr Y’s symptoms and carried out an examination which did not indicate any signs of an abdominal mass or cause for rectal bleeding upon rectal examination. Mr Y did not have any worrying vital signs and did not report any weight loss.
22. With regards to the bleeding, our adviser explained the records do not suggest there was clear occult blood in the faeces. The history recorded Mr Y had experienced bright red blood, which would suggest it was fresh blood, rather than blood in the stool.
23. The ED doctor then spoke with the consultant, who had a discussion with the general surgical registrar. Our adviser explained this would be a standard action to take with patients who present in a similar way to Mr Y, and we can see this is in line with the GMC’s Good Medical Practice guidance.
24. The general surgical registrar decided to arrange an outpatient appointment for a flexible sigmoidoscopy and provided safety netting advice to Mr Y to return if the bleeding continued, if he developed severe pain, or if he was feeling more unwell. Our adviser explained this was a reasonable treatment plan when taking into consideration Mr Y’s age and presenting symptoms.
25. We understand that there was no indication at that time for further investigations, such as a CT scan. The NICE CKS on the assessment and diagnosis of acute abdominal pain says investigations in secondary care may include an abdominal CT scan, where conditions such as abdominal sepsis or bowel obstruction are suspected. It also says investigations may include colonoscopy/sigmoidoscopy.
26. Our adviser confirmed Mr Y had no signs of sepsis or bowel obstruction, and so an immediate CT scan was not indicated. We can see Mr Y was referred for an outpatient colonoscopy/sigmoidoscopy based on his presenting symptoms. We understand there were no indications this needed to be done urgently.
27. Overall, we consider Mr Y’s management in the ED on 8 May 2022 was in line with the NICE and GMC guidance we have referenced above. Mr Y was assessed and examined, and advice was sought from a specialist. As there were no indications Mr Y required urgent investigations, an outpatient appointment was arranged to further investigate the cause of his symptoms. For this reason, we have not identified any indications for further investigation.