Three patients given colonoscopies by an NHS doctor died and three others suffered harm after they did not receive the appropriate follow-up care.
The Greater Glasgow and Clyde health board carried out a clinical review of people who had an colonoscopy performed by the consultant between 2020 and 2022.
The review covered 2,700 patients after a “very small number of patients” were identified as not receiving appropriate follow-up care following their procedure.
A report, completed in September, identified six patients who suffered harm – three of them died.
The consultant, who has not been named, was suspended in November 2022 and has since left the employment of NHS Greater Glasgow and Clyde (NHSGGC).
The health board’s investigation found that the doctor did not follow up the colonoscopies properly and missed the chance for patients to be treated – including several who developed malignant tumours.
Most of the procedures were for patients in the Bowel Screening Programme – which checks if you could have bowel cancer and is available to everyone aged 50 to 74 years old.
Patients and families affected have been informed of the outcome of the significant adverse event reviews that have been carried out into the cases, the health board said.
NHSGGC informed the General Medical Council (GMC) of its investigations when the issues first were identified and has continued to update the doctors watchdog of the progress of its review and findings.
Professor Colin McKay, deputy medical director at 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.”
A General Medical Council spokesperson said: “Our thoughts are with the patients affected.
“We are aware of the concerns and are looking into them.
“We are working closely with NHS Greater Glasgow and Clyde and other relevant organisations.”
A Scottish Government spokesperson said: “We are very concerned about this situation and sympathise with all the families affected, particularly those who lost a loved one.
“We note that NHSGGC took steps to fully investigate what occurred and the board has accepted recommendations from the significant adverse event reviews to ensure that lessons will be learned and that those recommendations and lessons will be shared with other health boards.”
A contact number for patients has been set up for anyone who may have concerns or questions about these issues.
Patients can contact 0141 451 5435 and the number will be staffed between 8am and 8pm Monday to Sunday.
Timeline of events in NHS Greater Glasgow and Clyde
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.
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