Guy’s and St Thomas’ NHS Foundation Trust

6. Mrs P complains about an endoscopy procedure (a test to look inside the body using a long, thin tube with a camera) at the Trust on 11 July 2020.

7. Mrs P says:

• the procedure was done without any anaesthesia • the Trust did not lubricate the endoscope • even when she signalled for the procedure to stop she was held down.

8. Mrs P says she was ignored when in pain and it has left her traumatised.

9. Mrs P says her neck, chest and head were swollen and painful after the endoscopy. She says this has affected her posture and she always leans to one side. Mrs P also says she cannot turn around easily or without pain due to a restriction in her spine and swelling.

10. Mrs P says she has to take painkillers every day but they do little to ease her pain. She says she can only sleep on one side.

11. Mrs P adds that underneath her breast is sore and she has a constant dripping sensation, making her feel breathless.

12. She believes the Trust broke her collarbone during the procedure.

13. Mrs P also says she now has severe depression and other health issues.

14. Mrs P is looking for an apology and a financial payment.

15. On 11 July 2020, Mrs P went to the Trust to have the endoscopy.

16. Mrs P complained to the Trust on 18 November 2020.

20. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any signs that something has gone wrong. We go into more detail below.

Anaesthesia

21. Mrs P’s medical records show the Trust gave local anaesthesia in the form of a throat spray before the procedure started. The consent form was signed by Mrs P and says that local anaesthesia was to be given and not a sedative.

22. We understand Mrs P chose to have the throat spray as she needed to take public transport home. Our adviser said it could have been dangerous to give Mrs P a sedative so it right for her to only have the throat spray.

23. The NICE guidance says, ‘The person may be offered sedation before the procedure, and/or given a local anaesthetic to numb the throat.’

24. We have not seen anything wrong with the Trust’s decision not to offer general anaesthesia or sedation and to use a throat spray to numb Mrs P’s throat instead.

Lubricant

25. We have seen no evidence in Mrs P’s medical records to suggest a lubricant was used during her procedure.

26. Our adviser said there is no guidance or policies to say a lubricant should be used during a gastrointestinal endoscopy. They also added in most similar procedures a lubricant is not used.

27. We are sorry to hear about the effects Mrs P said this procedure had on her. A lubricant is not a requirement for such procedures. We consider the Trust did nothing wrong by not using a lubricant.

Stopping the procedure

28. There is no suggestion in Mrs P’s medical records that she signalled for the procedure to stop, or she had to be restrained for the procedure to finish. The Trust said if Mrs P feels that any part of her procedure has not been noted correctly in her records, she can write to it explaining what she feels is wrong and it will add her letter to her medical records. From our understanding, Mrs P has not provided a letter yet.

29. Our adviser said if a patient withdraws their consent during a procedure or signals for a procedure to stop, it must be stopped.

30. The BSG guidance says, ‘We recommend that where a person objects during an endoscopic procedure, the procedure should be stopped.’

31. Our adviser said it is known for some patients to find the procedure uncomfortable and some patients cope by thumping the bed or hyperventilating. They add it is sometimes difficult to know what is consent being withdrawn and what is a patient coping with the procedure.

32. Mrs P’s medical records show the endoscopy lasted four minutes, which our adviser said shows it was not a prolonged procedure. The operation notes also show on a scale of 0 to 5, with 0 being the lowest level of discomfort, Mrs P scored the procedure as being ‘1’ which is described as mild discomfort. This suggests Mrs P tolerated the procedure and coped with the discomfort.

33. We also understand Mrs P was discharged from the Trust to take public transport home very shortly afterwards. There are no notes to suggest there was any concern by either the Trust or Mrs P about this.

34. Our adviser said the photographs from the procedure are very clear and accurate. They said this would suggest Mrs P was still and the photographs were not taken in a hurry. They said photographs can become unclear if the patient is moving.

35. While we will never know exactly what happened during the procedure, we are sorry to hear of Mrs P’s experience.

36. We need to base our decision on the evidence we have. This includes medical records, complaint files, patient accounts of what happened and advice from our advisers. Where evidence contradicts each other, as in this case, we would look to see what is most likely to have happened.

37. Apart from Mrs P’s account of what happened, most of the evidence suggests the procedure ran smoothly and she did not signal for the procedure to stop. We understand Mrs P may have experienced some discomfort but not to an extent where the procedure needed to stop.

38. We understand this will be disappointing to Mrs P but we hope our consideration gives her some assurance.

39. We thank Mrs P for bringing her complaint to us.

1. We have carefully considered Mrs P’s complaint about Guy’s and St Thomas’ NHS Foundation Trust (the Trust). We have seen no sign that anything went seriously wrong.

2. Mrs P raised concerns that the Trust did not give her any anaesthesia (pain relief), we saw the Trust prescribed her with a throat spray before the procedure started. We consider this was the right thing to do and was in line with the relevant guidance.

3. We considered Mrs P’s concerns that the Trust did not use lubricant. We have been unable to find any guidance or policies which suggest lubricant is needed for the procedure so we do not think the Trust did anything wrong.

4. Mrs P also complains the Trust continued with her procedure despite her signalling for it to stop. She says she was held down. We saw no evidence in Mrs P’s medical records that she signalled for the Trust to stop the procedure or that she had to be held down. When we do not have evidence to support an account, we make a decision based on what we think most likely happened. In this case, apart from Mrs P’s account, all other evidence suggests Mrs P consented to the procedure and there were no issues.

5. We are sorry to hear about Mrs P’s concerns and the pain and symptoms she has been dealing with. We understand our decision will be difficult for her to read but we hope she feels reassured the Trust acted in line with guidance.