Case of the month: November 2019 - forget me not


About this case study

Each month JAG publishes a case of the month highlighting a real life clinical scenario which has impacted patient safety. Case studies are contributed by JAG leads and endoscopy services across the UK and are designed to provide an opportunity for discussion and to share learning. 


Download the PDF version here and share this for discussion with your team.


Case synopsis

A 64-year-old woman was referred for progressive reflux symptoms. She had no past medical history. She was triaged directly to oesophago-gastroduodenoscopy (OGD) and a patient information leaflet about the procedure was sent with the appointment letter.

The patient was admitted by an experienced endoscopy nurse. The patient was allocated to a senior gastroenterology trainee’s list. The trainee consented the patient for OGD. The patient elected to have no sedation but received throat spray. The initial intubation was straightforward but poorly tolerated. The trainee was uncertain of the view obtained which looked ‘unusual’. They called for a senior endoscopist’s advice.

A consultant immediately came to the room and agreed the views were ‘unusual’, and concerning for a high oesophageal perforation. The procedure was terminated and the patient was taken to recovery.

The patient had mild discomfort in the neck. The trainee explained their concerns to the patient and daughter and the patient was kept nil by mouth. After 20 minutes, she became more uncomfortable and on examination surgical emphysema was detected. Another consultant (the clinical lead for endoscopy) attended to the patient. A CT scan was immediately requested and the surgical team was contacted.

A CT scan confirmed a perforation. The upper GI surgical team at the local referral centre were contacted immediately and transfer arranged. The following day the patient underwent surgical repair of the perforation. The patient had a protracted recovery but left hospital well 6 weeks later. 
A full investigation of this complication was carried out. The investigation and outcomes were fully documented and discussed at an endoscopy governance meeting. The endoscopist and clinical lead for endoscopy made several follow up calls to the surgical team following transfer. The clinical lead met with the patient’s daughter and explained the review process following a serious complication such as this. The clinical lead wrote to the patient’s GP to explain the circumstances of the complication and need for transfer to another hospital.

Eight weeks later, following discharge, the patient made a formal complaint to the hospital raising the following issues:
Why was a ‘trainee’ performing a procedure unsupervised?
Why were they not consented for the possibility of such a serious complication?
Why had they not received any apology or letter from the hospital following the transfer to another hospital?

The investigation report was shared with the patient and she was invited in to discuss the findings with the clinical team. The investigation had found that:

The ‘trainee’ endoscopist had demonstrated all the necessary competencies and was JAG certified. They had been supervised on many occasions by two different consultants in recent weeks and no concerns had been raised about their ability to perform gastroscopy [1]. 
The consent form was in the patient record and clearly documented the risks for both perforation and bleeding, however, both copies (patient and top copy) of the consent form were in the notes.
The hospital apologised that although the daughter had been spoken to and the GP had received a letter outlining what had happened, the patient had not been written to. They acknowledged that at the very least, the letter to the GP should have been copied to the patient.
Prompt and correct action had been taken by the team in the immediate hour following the event. Urgent transfer had been correctly organised and documentation of the events had been excellent.


JAG analysis

What are the learning points you took away from this case?
How could things have been improved?

The following patient safety incidents were identified by JAG. They have been categorised for severity (mild, moderate and severe) based on the actual or potential impact to the patient and adherence to clinical guidance, as well as by theme [2]:

1. Oxygen monitoring
2. Distractors and time management 
3. Non-technical skills and training
4. Documentation and reporting errors
5. Technical skills and equipment 
6. Sedation intravenous access and monitoring
7. Drug errors
8. Consent 
9. Histology and sampling errors
10. Administrative error

Patient safety incident



Communication from the hospital was inadequate following 

The consent form was completed thoroughly but not given to patient8Moderate

There was no documentation of events and outcomes conveyed directly to patient


Did you identify any other patient safety incidents?


1. Following an adverse event or complication, communication with the patient should continue until the issue is fully resolved and the patient should be invited to discuss what happened as soon as they have recovered [3]. In this case, transfer to another hospital meant that communication broke down. The letter to the GP could have been copied to the patient to inform her that she had the opportunity to meet on discharge.

2. Patients should be offered a copy of their consent form to keep a record of benefits, risks and discussions around a procedure. Development of the complication meant that usual discharge processes were not followed as urgent transfer was the priority. As a result, the patient’s copy of the report and consent form did not go to the patient.

3. Documentation by the team involved is crucial following an adverse event. Often, in the heat of the moment, the priority is to manage the patient. If the patient is transferred, notes should follow the patient. Those involved should write contemporaneous notes so that if there is an investigation or a complaint at a later date there is a full record of what happened.

4. The term ‘trainee’ maybe confusing and misleading to patients and we ought to consider other terms in view of competence. In this case, there was no suggestion that the trainee acted incompetently and in fact they immediately recognised the complication had acted promptly following good practice and current guidelines [4,5].

Insights from our JAG patient representative, Catherine Patterson

With no past medical history, it might be safe to assume that a normally healthy individual coming in for a procedure will not be accustomed to being in a clinical environment. To some, this might not make a difference, but it’s worth taking notice of how an individual patient might be absorbing what they're being told. To some of us lay people, just the fact of being in a hospital, awaiting an unfamiliar procedure or treatment, can be bewildering. 

I agree that the use of the word ‘trainee’ is misleading. If a practitioner is deemed competent enough to perform the procedure, the concept of being a ‘trainee’ might only serve to make a nervous patient more ill at ease. I can’t emphasise enough how important both verbal and written communication with the patient is. Clearly there are situations where you may have to deal directly with a relative or carer. Regardless of who else is supporting the patient, always remember to view them as the most important person to have dialogue with.

Paperwork can be reassuring. It highlights the risks but it also reminds the patient that the people taking care of them have ‘dotted the i’s’. Don’t forget to hand it over if it's required.

Do you have a case study from your service which you would like to share in the next ISREE case study of the month?

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1. JAG. OGD application criteria and process; Available from: - certification for trainees/OGD application criteria and process.pdf.
2. Matharoo, M., et al., A prospective study of patient safety incidents in gastrointestinal endoscopy. Endoscopy international open, 2017. 5(1): p. E83-E89.
3. General Medical Council. Openness and honesty when things go wrong: the professional duty of candour. 2015; Available from:
4. British Society of Gastroenterology. Guidelines on Complications of Gastrointestinal Endoscopy. 2006; Available from:
5. Paspatis, G.A., et al., Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy, 2014. 46(08): p. 693-711.

This case is informed by real-life events and the narrative has been adapted to enhance educational benefit. No identifiable information has been provided.

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