NHSGGC has carried out a clinical review of patients who had a colonoscopy between 2020 and 2022 performed by one of its doctors.
The comprehensive look-back exercise of 2700 patients was instigated following identification of a very small number of patients who had not received appropriate follow-up care.
The review, completed in September, identified six patients who suffered harm among the patients who were not followed up appropriately. Sadly, three of the patients died.
The consultant was suspended in November 2022 and has since left the employment of NHSGGC.
Patients and families affected have been fully informed of the outcome of the significant adverse event reviews that have been carried out into these cases.
NHSGGC informed the General Medical Council (GMC) of its investigations when the issues first were identified and has continued to update the GMC of the progress of its review and findings.
Professor Colin McKay, Deputy Medical Director, NHSGGC said: “We would like to offer our sincere apologies to patients who were not followed up appropriately and our condolences to the families of those patients who have died.
“When errors were first discovered, an immediate, comprehensive review was carried out of all cases managed by the doctor since 2020.
“Our investigations found that the doctor did not consistently follow up the results of investigations that had been completed or requested and therefore missed the opportunity for patients to be treated, including a number of patients who went on to develop malignancy.
“We would like to reassure patients that we have already contacted all those patients affected and that no other patients should be concerned that they may be involved.
“We will ensure that recommendations and any other learning from our review will be shared with other Health Boards.”
The vast majority of colonoscopies performed by the doctor were for patients in the Bowel Screening Programme. The review covered the period from January 2020 as there was review evidence of appropriate follow up prior to then.
A contact number for patients has been set up for anyone who may have concerns or questions about these issues. The number is 0141 451 5435 and is staffed between 8am and 8pm Monday to Sunday.
Timeline
March 2022 – first patient is identified
May 2022 – review of case completed. It was considered at the time that this was an isolated administrative error and there were no other signs to suggest a wider issue. No previous incidents of this nature had been raised.
August 2022 – second patient is identified. Patient safety-focussed review is commissioned, initially on those patients who had undergone colonoscopy by the endoscopist between April and August 2021
September 2022 – outcome of review of cases highlights further issues and disciplinary investigation and formal review into the doctor’s practice commenced
A full review is undertaken into all colonoscopies carried out by the doctor during the period 2020 to November 2022.
An initial electronic exercise was carried out with the aim of rapid identification of patients most at risk. To provide further assurance a manual review of electronic scheduling diaries and other data sources was subsequently carried out and all remaining colonoscopy cases by this practitioner from 2020 onwards had case record review by the review team. Following this review more than 100 patients who had colonoscopy undertaken by this doctor have been appointed as overdue their follow up colonoscopy.
September 2023 – Detailed review of patient records and follow up for affected patients is completed.
Background
The name of the doctor is not being made public as disclosure of the individual’s identity would potentially breach our obligations under Data Protection Legislation.