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Learning from cases: Gastroenterology

Post date: 24/09/2020 | Time to read article: 11 mins

The information within this article was correct at the time of publishing. Last updated 15/06/2022

Written by a Senior Professional

Learning from case: Gastroenterology

Gastroenterology is a unique field, so the advice you receive needs to be equally specialised.

We’ve developed this collection of analysis, statistics and case studies from our extensive library to give you a view of the current claims landscape for your specialty.

The accompanying learning points also help you to avoid the problems others
have faced.

When you are a Medical Protection member, you benefit from more than 130 years of experience defending doctors and other healthcare professionals. That isn’t just a number – it’s 13 decades of specialist expertise that we use to protect you long into the future.

Introduction

Gastroenterology has developed into a branch of medicine involving many different and advanced therapeutic endoscopic procedures. Each procedure has associated inherent risks and complications. Sometimes, endoscopy procedures do not go as planned, but the impact is inconsequential. However, a series of minor adverse events may culminate in a significant adverse event. Medicolegal cases are not uncommon due to the significant impact the complications can have on patients’ lifestyles.

We know that population-based bowel cancer screening exposes healthy, asymptomatic individuals to sedation and invasive procedures.

Most cases reported to Medical Protection relate to elective procedures undertaken
outside the NHS.

Claims in gastroenterology can sometimes lead to large financial settlements.

The value of a settled claim will often include compensation for care and loss of earnings, if applicable, in addition to an award for the damage that resulted from a breach of duty. Complications can result in the patient requiring additional surgery – such as an ileostomy or colostomy – and, in some cases, death. The value of each claim varies enormously, with our highest gastroenterology total case payment (claimant damages, costs and legal costs) 2006-2015, being well in excess of £700,000.

We understand that you work in complex and pressured environments. We know following feedback from members that experiencing a medicolegal case can be concerning and a source of stress. At Medical Protection we want to share our knowledge, experience and expertise with you to provide professional support that we hope you find valuable.

Analysis

We’ve analysed the support Medical Protection has provided to UK-based gastroenterology members in over 300 cases. We have provided advice and assistance in writing medical reports and supported our gastroenterology members in relation to claims (demands for monetary compensation that embodies allegations of negligence), pre-claims (intimations from a claimant of a possible claim for compensation), complaints, GMC investigations, local disciplinary procedures, inquests and criminal investigations.
We have analysed all claims, including those defended, not pursued and settled. We feel that sharing our learnings from the reasons patients decide to take action is valuable, as well as the reasons why claims are settled.

Cases Opened by Type 2008-2017

UK Gastroenterology

Gastroenterology pie chart


Types of procedures leading to patients making a
claim and common contributory factors

Delay in diagnosis or treatment

Almost half of the claims related to a delay in diagnosis or treatment, and of these claims the highest number of claims related to the delay in diagnosis or treatment of cancer of the gastrointestinal tract, including stomach, pancreas, small and large bowel. We acknowledge that some stomach and pancreatic cancers can be more difficult to diagnose in patients who present with vague symptoms. Patients often claimed for compensation if they felt their gastroenterologist should have detected their cancer earlier.

In some cases, there were allegations of delays in diagnosing Crohn’s disease, ulcerative colitis or gallstones. In our analysis of claims, we identified four key themes of contributory factors behind delays in diagnosis or treatment:

  • misdiagnosis of benign disease
  • mismanagement/communication of test results
  • failure to follow current national guidelines
  • inadequate safety netting advice resulting in delayed re-presentation.

Misdiagnosis of benign disease 

There were claims of delays in diagnosis where patients had already been investigated
for the same or similar symptoms and had previous negative test results. In some cases, initial investigations for patients with bowel symptoms were reported as benign, for example, liver lesions on a CT scan being reported as haemangiomas. Allegations were made that if a colonoscopy procedure had been done sooner large bowel cancer with liver metastases would have been diagnosed sooner, there were a few cases where symptoms were attributed to helicobacter pylori, but the patients were later found to have stomach cancer. There were some cases where pancreatic lesions on a CT scan were reported as benign pancreatic cysts.

Mismanagement/communication of test results

Our analysis of claims highlighted that inadequate processes to follow up test results can lead to claims alleging delays in diagnosing cancer. We have settled claims where inadequate communication of histopathology biopsy results between hospitals, gastroenterologists and patients had resulted in months of delays in commencing treatment. Contributing factors included one case where results had been filed in the patient’s records by administrative staff without being reviewed and actioned by a gastroenterologist. Another case saw delays in a patient receiving biopsy results from both their gastroenterologist and GP.

 

Failure to follow current national guidelines

The British Society of Gastroenterology (BSG) and NICE regularly update their guidelines relevant to the field of gastroenterology. We have had a few claims where the gastroenterologists had used out of date national guidelines that had been superseded. This resulted in failures to undertake annual surveillance colonoscopies, as suggested in the relevant guideline, resulting in delays in diagnosing of cancers.

Inadequate safety netting advice resulting in delayed re-presentation

In our analysis of claims of delays in cancer diagnosis, some joint allegations of negligence were made against GPs, NHS hospital trusts and gastroenterologists providing private healthcare. Diagnosing some cancers in patients who present with vague symptoms can be challenging. It is not uncommon for patients to consult healthcare professionals a few times before suspected cancer referrals are made. Some cancers are diagnosed following emergency admission to hospital. Patients were more likely to take action if they were uncertain why, when and with whom they should have re-consulted and if they had difficulty making a repeat appointment.

 

Our highest gastroenterology case total payment was in excess of £700,000.


Endoscopic complications

The second most frequent claim was complications following an endoscopic procedure.
In more than 10% of claims from our data the patient experienced a perforation, specifically during gastroscopy, colonoscopy, sigmoidoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). The most frequent perforation occurred during a colonoscopy. The common contributing factors leading to claims being settled following perforation were:

  • inadequate consent
  • inadequate documentation
  • delay in managing complications.

When the documentation around consent was reviewed it was judged to be inadequate
by our experts in some claims following perforation during an endoscopy procedure. The detail of the risks on the consent forms that were used was considered lacking and there was no documentation in the patients’ records to confirm what had been discussed with the patients. In addition, the patient information leaflets given sometimes provided very limited information. Some patients developed pancreatitis following ERCP and made claims of negligence against their gastroenterologist. A number of these claims were settled because the consent process was considered to lack specific detail about the ERCP procedure and the risk of complications including pancreatitis. Claims were more likely to be defended when there was clear documentation of all the steps to provide evidence of a detailed interactive discussion with the patient.

A BSG working party has developed a standards framework that sets out the standards of performance and safety to improve the quality and availability of ERCP in the UK.

The BSG guidelines recommend: “It is particularly important that patients are aware of the risks of perforation and bleeding, that complications may be delayed and that surgical intervention may be required. The magnitude of risk should be clearly documented.”

In some claims it was alleged that perforations undetected at the time of the endoscopy should have been diagnosed and treated sooner. Expert witnesses have criticised some gastroenterologists for insufficient monitoring leading to delays in detecting deterioration in vital patient signs. Cases were more likely to be settled if the documentation was limited, in particular if more immediate action to manage complications was necessary.

 

Case Study

The situation

An 81-year-old woman underwent a privately performed colonoscopy by a consultant gastroenterologist for investigation of ongoing abdominal pain and constipation.

Her past medical history included atrial fibrillation for which she was taking warfarin. This was not stopped prior to the planned procedure. She was consented for the risk of bowel perforation and the possible need for a biopsy if any polyps or lesions were identified and provided with an information leaflet.

At the time of colonoscopy, a 6mm flat polyp was visualised in the vicinity of the hepatic flexure. The consultant felt this required removal rather than biopsy but was unable to proceed with polypectomy due to the patient’s anticoagulated status, and a further colonoscopy with polypectomy was scheduled for six weeks later. The patient was advised to discontinue warfarin for five days prior to undergoing the second procedure.

At the time of the repeat colonoscopy, three flat polyps of 5mm – 10mm diameter were identified in the region of the hepatic flexure. All three were biopsied using hot diathermy forceps. The procedure was considered to have been uncomplicated and the patient discharged home.

Histology ultimately demonstrated benign tubular adenomas showing low grade dysplasia.

Several hours after the procedure, the patient attended the emergency department via ambulance complaining of severe lower abdominal pain in conjunction with nausea and feeling shivery.

On examination she was found to have a diffusely tender and slightly distended abdomen. Her white cell count was raised. An abdominal x-ray and erect chest x-ray were reported as being normal, but a CT scan of her abdomen revealed free air within the upper abdomen overlying the liver. Free fluid was identified around the right lobe of the liver and hepatic flexure, and the hepatic flexure was noted to be oedematous.

It was considered the likely diagnosis was colonic perforation, although no definite site of perforation was identified, and an emergency laparotomy was performed. This identified a perforation to the right colon, which was repaired. The patient made a reasonable recovery and was discharged home a few days later.

The case

The patient later brought a claim of clinical negligence against the gastroenterologist alleging that it was a breach of duty to perform a hot biopsy technique to destroy the polyps, and that the use of diathermy caused the bowel perforation.

The outcome

Gastroenterology expert opinion was sought in this case and the matter was settled for over £125,000 because:

The consent taken from the patient appeared to be limited as a detailed discussion of the risks and benefits of colonoscopy, biopsy and polypectomy was not clearly documented, and the information contained within the leaflet was insufficient.

There was no evidence to suggest that alternatives to diagnostic colonoscopy, such as CT colonography, were discussed.

There was no evidence to suggest that alternatives to endoscopic polyp removal, including the possibility of doing nothing, were discussed.

It was inappropriate to use a hot biopsy technique for polypectomy on the right side of the colon as per the British Society of Gastroenterology 2008 guidance, Colonoscopic Polypectomy and Endoscopic Mucosal Resection: A Practical Guide, which states there is a risk of transmural thermal injury if hot biopsy is performed in the right colon where the colonic wall is thin.

It is likely to have taken a considerable amount of diathermy to destroy a polyp of 10mm in size and it would have been preferable to remove this via endoscopic mucosal resection rather than diathermy destruction.

On the balance of probabilities, the use of diathermy resulted in perforation of the bowel.

Learning points

  • Consider and discuss the options available with the patient, including the advantages and disadvantages of each possibility.
  • Ensure any discussion regarding consent is detailed and fully documented in the contemporaneous records.
  • Follow current available guidelines or, if deviating from guidance, be certain that this decision can be explained and justified

 

 

This case is based on a real scenario, with some facts altered to preserve confidentiality. 

Patient complaints – common themes

When we analysed the patient complaints reported to Medical Protection there were
some similar themes to the claims, but also some new themes.

  • The clinical judgment of the doctor or the management of the care of the patient was a reoccurring theme in nearly half of the complaints, for example not keeping the patient informed/lack of explanation of progress and discharge procedures, or the production of an inaccurate discharge letter.
  • Issues regarding consent were also prevalent in complaints.
  • Failures and delays to diagnose were alleged in some of the cases. These include alleged delay in undertaking further tests/procedures, for example colonoscopy and alleged failure to diagnose bowel cancer.
  • Improper rectal examinations or sigmoidoscopies, including inadequate consent, inappropriate comments, painful examinations or no chaperone.
  • Some complainants reported being unhappy with their doctor’s manner and attitude, and rudeness during the consultation. Some of these communication issues resulted in the patient feeling that the proposed procedure had not been adequately explained to them.

Regulatory and disciplinary cases – common themes

Regulatory and disciplinary cases can come from patients and senior or junior colleagues and can be related to clinical and non-clinical issues.

  • Performance concerns: operative/clinical skills, clinical judgment and communication.
  • Inappropriate personal behaviour/misconduct/boundaries and poor communication with colleagues.
  • Probity concerns including incorrect coding and billing.
  • Inappropriate delegation or supervision.
  •  Member health issues including alcohol and drug addictions.

Medical Protection has assisted members in writing statements and attending coroners’ inquests. An inquest is a fact-finding exercise that is conducted by the Coroner and, in some cases, in front of a jury. The purpose of an inquest is to find out who died – when, where, how and in what circumstances. Medical Protection’s Inquest factsheet gives further information about what happens at an inquest.

Members have requested assistance form Medical Protection with inquests where patients had died following perforations during endoscopic procedures.

  • From our analysis, in most of these cases the perforation occurred whilst performing ERCP.
  • Perforations occurred in other endoscopic procedures such as colonoscopy and gastroscopy.
  • The other cases were regarding death following thromboembolism, liver failure/disease, pancreatic cancer, aspiration pneumonia and myocardial infarction.

Top tips to minimise risk

Please note this not an exhaustive list of recommendations but key learning points from
our analysis:

• Ensure your endoscopic technique is in line with current best practice such that it
would be supported by your peers.

• Keep up to date with current BSG and NICE guidelines. Be aware if new information
becomes available in relation to surveillance intervals or risk of disease.

• To reduce the risk of delays in diagnosis explain the uncertainty about the cause of
symptoms to patients, ensuring they understand why, when and with whom they
should re-consult about which concerning symptoms.

• Listen to what your patient would consider to be a successful outcome. Understand
your patient’s concerns and expectations.

• Discuss the possible benefits and risks of all potential treatment options. Consider
what is most important to that individual, given their specific circumstances.

• Explain about frequent and serious complications and the implications for
the individual patient if these occurred. Explain what you would do to correct
complications.

• Explain what the procedure will involve, the likely results and when you will see the
patient afterwards.

• Double check that the information has been understood and decisions are correctly
informed. Never pressurise or rush patients into giving consent to have an endoscopy.

• Clearly document all the steps to provide evidence of a detailed interactive discussion:
this is vital for legal purposes.

Be aware that there are risks associated with delegating giving advice and taking
consent, for example the patient may be dissatisfied and claim later that they did not
fully understand the procedure.

• For elective procedures always leave sufficient time (for example at least a week) after
the consultation before scheduling the procedure to allow patients time to think things
through, talk to their family or access more information.

• Ensure an endoscopy safer checklist/proforma is completed including:
- patient identity
- proposed procedure indication and consent
- preference for sedation
- relevant comorbidities for example, anticoagulation, drug allergies
- correctly functioning equipment
- correctly labelled histology samples
- clear follow up plan, including informing patients of the results of investigations.

• Ensure close monitoring takes place after endoscopy and any deterioration is managed in a timely and appropriate fashion.

• When things go wrong the vast majority of patients just want two things: an
explanation and an apology.

• Ensure you are fully indemnified to carry out the relevant procedures in the UK.

Support for your professional development

Face-to-face and virtual workshops from Medical Protection:

Face-to-face workshops:

  • Mastering Adverse Outcomes
  • Mastering Your Risk
  • Achieving Safer and Reliable Practice
  • Mastering Consent and Shared Decision Making.

Virtual workshops:

  • Navigating Adverse Outcomes
  • Reducing Medicolegal Risk
  • Consent and Shared Decision Making.

Online learning
Complete a range of e-learning modules, including communicating risk, preventing complaints and communication after an adverse even. All included as a benefit of membership at no extra cost.
Access online learning at medicalprotection.org/cpd

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