Mr. N, a gentleman in his 80s, visited his GP in Coventry due to altered bowel function, including diarrhoea and weight loss over two months. He was referred for a CT colonoscopy, which revealed a stricture in the descending colon, raising suspicion of cancer. A virtual colonoscopy confirmed these findings, leading to a flexible sigmoidoscopy where biopsies were taken. Histological analysis indicated high-grade dysplasia with desmoplastic invasion, suggesting a moderately differentiated adenocarcinoma (i.e. cancer).
Mr. N was advised to undergo a left hemicolectomy (removal of the affected part of bowel), likely requiring a permanent stoma. To assist with this, he had a further sigmoidoscopy when the tumour site was to be tattooed to assist with the surgery; however, the clinician mistakenly tattooed a healthy segment of the distal sigmoid instead of the tumour. Mr N then underwent the surgery as planned, with the result being that an incorrect (and healthy) piece of bowel was removed, leaving the cancer still in place.
Another flexible sigmoidoscopy was performed through the newly created stoma, where the original tumour was again located and (this time) correctly marked). Mr. N then had a second laparoscopic Hartmann’s procedure to remove more bowel along with the tumour. Postoperatively, he was admitted to the Intensive Treatment Unit (ITU) for monitoring before being discharged.
An expert review concluded that Mr. N received substandard care, particularly due to the tattooing error. Whilst the prognosis of the cancer was unaltered, the timing and need for a second surgery within two months negatively impacted his recovery, especially given his advancing years. An agreement for compensation of £32,000 was reached.
