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Selected Investigations Completed April - September 1999 > Part I, Case no. E.289/98-99
Complaint against: Southport & Ormskirk Hospital NHS Trust (formerly West Lancashire NHS Trust)
Summary of case
In April 1997 Mrs V was referred to the A & E department of Ormskirk and District General Hospital suffering from severe anaemia, diarrhoea, weight loss and pain in her lower abdomen. She was admitted and given a blood transfusion. A gastroscopy was performed which showed a hiatus hernia. A barium enema showed diverticulitis. An ultrasound test was reported as normal and Mrs V was discharged from hospital on 24 April. A colonoscopy was carried out in July and confirmed the diagnosis of diverticular disease. On 1 September Mrs V was seen by a consultant surgeon. He prescribed iron tablets and planned to review her in two months. On 1 October, while on holiday abroad, Mrs V was admitted to hospital. On examination a palpable mass was found in her lower abdomen. A CT scan was followed by surgery to remove a cancerous mass measuring 11 x 9cm from her caecum (lower bowel).
Findings
The Ombudsman was advised by independent professional assessors. He found that a consultant radiologist had carried out a suboptimal barium enema investigation. A gastroenterologist, who performed the colonoscopy, said that he reached the caecum - the site of Mrs V's cancer - in 90% of cases, including Mrs V. The Ombudsman was advised that a colonoscopy was a difficult procedure and that degree of accuracy was unlikely. The consultant radiologist and gastroenterologist failed to perform and interpret their procedures adequately. The consultant surgeon did not question the reports of his colleagues. He did not examine Mrs V on 1 September when it was very likely that he would have felt the mass in her abdomen. The Ombudsman concluded that the care given to Mrs V was less than adequate. He upheld the complaint that Mrs V's condition was undiagnosed and there was an avoidable delay in treating her bowel cancer.
Remedy
The Trust apologised. They agreed to consider whether, as a matter of good practice, clinicians commissioning investigatory work should discuss their concerns with the specialist concerned. Should the outcome of the investigation not support a firm clinical diagnosis and where there is a suspicion of a serious condition such as cancer, a patient should always be re-examined.
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