A recent civil trial in the District Court of Queensland (Coulon v Adams [2022] QDC 291) relating to the alleged negligent performance of a colonoscopy was lost by the plaintiff.
Summary of the facts
Mrs Mary Coulon elected to undergo a colonoscopy following a lifetime of constipation and recent onset of nausea and rectal bleeding, and after consulting with Dr Adams, general surgeon, about these symptoms. On 7 March 2018, the colonoscopy was performed by Dr Adams in a private hospital. Dr Adams found the procedure difficult due to “looping with a redundant colon” which meant that “she was unable to proceed past the distal ascending colon”. Mrs Coulon was discharged from hospital on the same day.
The following day, Mrs Coulon felt unwell and was in significant pain. A CT scan was performed which demonstrated “a large ruptured subcapsular splenic haematoma”. Mrs Coulon’s spleen was subsequently removed. As a result of the removal of the spleen, Mrs Coulon requires lifelong antibiotic therapy.
A redundant colon, also known as a tortuous colon, is an abnormally long colon that cannot fit inside the body without twisting or looping. This often causes gastrointestinal problems, such as constipation, because digested food takes longer to travel through the colon.
The duty of care
It was alleged that Dr Adams owed Mrs Coulon a duty of care to perform the colonoscopy to a reasonable clinical standard.
It was alleged that the duty extended to ensuring the colonoscope was appropriately manipulated to avoid damage including splenic injury.
The plaintiff alleged that not only had Dr Adams failed to manipulate the colonoscope correctly but had used excessive force.
Evidence of Dr Adams, the defendant
Dr Adams gave evidence that because of the twists and length of the bowel, the procedure was slow going. Due to the length of the bowel and the twists, Dr Adams decided to change to a longer colonoscope. The doctor withdrew the colonoscope carefully the entire way out and starting again with a longer colonoscope. The doctor came to a point where she felt she was not making progress and so decided to abort the procedure, describing the procedure as relatively uneventful.
The medical expert evidence
The plaintiff relied on the evidence of Dr Goodman, general and gastrointestinal surgeon. Dr Goodman’s opinion was that splenic injury is very rare and therefore, on the balance of probabilities, should not have occurred. The doctor further opined that when splenic injury does occur, it is always due to inappropriate manipulation of the colonoscope and is always the fault of the surgeon or endoscopist.
During cross-examination Dr Goodman “admitted that the only evidence with which he relied upon to make this statement was his own experience and that of his colleagues and that he could not provide any literature or direct evidence for this statement…” .
The defendant relied on the evidence of Professor Hourigan, interventional gastroenterologist, who was of the view that the incidence of splenic injury is much more common that published figures and that significant manipulation of the colonoscope, or excessive force, was not necessarily required to cause significant splenic injury. The Professor gave evidence that there is no doubt looping can occur despite the best efforts of the operator to prevent it. Further, Professor Hourigan explained that the plaintiff had a number of risk factors for splenic injury.
Additionally, there was no direct evidence that Dr Adams did anything in error and it was noted that the doctor impressed the Court as being a “very careful and methodical person”.
The outcome
Ultimately, the Court preferred the evidence of the defendant’s expert noting that it appeared more logical and that Dr Hourigan gave “careful, considered evidence and impressed with his objective approach to the subject”. In contrast, Dr Goodman relied upon a medical article, apparently in support of his position, but which he had not read and which, in some respects, presented the opposite of his views.
The plaintiff’s claim was dismissed.
Our views on colonoscopy cases
It might surprise some of our readers to know that damage to the bowel – such as to the wall of the bowel or putting a hole in the bowel (puncture) – and injury to surrounding structures (such as the spleen) are recognised risks of a colonoscopy, although they rarely happen. That is, they can occur without negligence. In our experience, the vast majority of general surgeons will provide warnings of these known risks. We note, in this case, that the plaintiff did not allege a failure to warn in the pleadings and so a finding on this issue was not open to the court at trial. In any event, the court accepted the evidence of Dr Adams that she did provide an appropriate warning as to the risks and that a warning would not have changed the mind of Mrs Coulon that it was desirable to have the procedure, as all of the medical experts considered the risks were rare and the procedure was appropriate.
In our experience, claims for compensation arising out of a colonoscopy do not always arise out of what occurred before – or during – the procedure, but what occurred post-operatively in recovery and prior to discharge. We have acted for patients who were discharged from hospital when they were showing signs and symptoms of a developing issue, or who were not given appropriate information about “red flag” signs to look out for. For example, commonly reported symptoms of injury to the bowel or other structures include abdominal pain or discomfort located over the left upper quadrant, referred pain to the left shoulder and non-specific symptoms of nausea, vomiting and abdominal distension.
We have acted for patients who have required colostomy bags or suffered life-threatening consequences of a delay in diagnosis of, and provision of appropriate treatment for, injury to organs during a colonoscopy.
Conclusion
There are increasing numbers of colonoscopies being performed for colorectal diseases. Further, there is anecdotal evidence that some people schedule colonoscopies routinely as part of their general health check ups.
Colonoscopies are not without risk. Delay in diagnosis of injury from a colonoscopy may result in adverse outcomes for the patient.
If you have suffered injury as a result of an endoscopic procedure, such as a colonoscopy, careful preparation of your case and expert selection is critical to the prospects of success.
Please contact our office for a confidential and obligation free discussion with our experienced medical negligence team.
