Concerns raised 2 Lack of clinician knowledge about the increased risks of diagnostic colonoscopies in the 80+ age group View source Lack of clinical guidance on the increased risks of diagnostic colonoscopies in the 80+ age group View source
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Vivian Joan Tuddenham NOLAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Vivian Joan Tuddenham NOLAN underwent a diagnostic colonoscopy on 31 March 2025 after referral for iron deficiency anaemia and a positive FIT test. She developed a colonic perforation, deteriorated despite medical and surgical treatment, and died on 10 May 2025. The concern was that clinicians may lack knowledge and guidance about the increased risks of diagnostic colonoscopy in people aged over 80.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician knowledge about the increased risks of diagnostic colonoscopies in the 80+ age group
Wider context from the report “1. During the course of the inquest hearing, I heard evidence from the Consultant Surgeon who performed the diagnostic colonoscopy. Their evidence included that, in their view, there ought to be a higher clinical threshold for offering diagnostic colonoscopies to patients aged over 80 given the associated, increased risks. Their evidence included that there is a higher clinical threshold in other countries for offering this diagnostic investigation to the 80+ age group.
My concern is that there is a lack of knowledge amongst , and lack of clinical guidance available to, clinicians as to the potential increased risks of diagnostic colonoscopies in the 80+ age group .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical guidance on the increased risks of diagnostic colonoscopies in the 80+ age group
Wider context from the report “1. During the course of the inquest hearing, I heard evidence from the Consultant Surgeon who performed the diagnostic colonoscopy. Their evidence included that, in their view, there ought to be a higher clinical threshold for offering diagnostic colonoscopies to patients aged over 80 given the associated, increased risks. Their evidence included that there is a higher clinical threshold in other countries for offering this diagnostic investigation to the 80+ age group.
My concern is that there is a lack of knowledge amongst, and lack of clinical guidance available to , clinicians as to the potential increased risks of diagnostic colonoscopies in the 80+ age group .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publicise the guidance to members through newsletters, podcasts and webinars.
Verbatim wording from the response “This guidance has been published in Gut, the foremost journal for gastroenterology practitioners and widely publicised to BSG members in newsletters, podcasts and webinars since publication. We have no evidence to suggest that this practice is not being followed nor of evidence to suggest that clinicians are not considering these factors prior to undertaking colonoscopy.” Source location Response from British Society of Gastroenterology
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance on individualised consent and diagnostic colonoscopy selection for patients with frailty or limited life expectancy.
Verbatim wording from the response “The British Society of Gastroenterology published guidance on this individualised approach to informed consent in 2023.(2) In April 2025, the BSG also published guidance on the Management of Colorectal Polyps in Patients with Limited Life Expectancy.(3) This document includes careful advice about patient selection for diagnostic colonoscopy.” Source location Response from British Society of Gastroenterology
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Published guidance and publicity provide sufficient awareness of increased colonoscopy risks; there is no evidence clinicians are failing to consider relevant factors.
Verbatim wording from the response “This guidance has been published in Gut, the foremost journal for gastroenterology practitioners and widely publicised to BSG members in newsletters, podcasts and webinars since publication. We have no evidence to suggest that this practice is not being followed nor of evidence to suggest that clinicians are not considering these factors prior to undertaking colonoscopy.” Source location Response from British Society of Gastroenterology
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinical thresholds for colonoscopy should not be based on age alone; decisions should assess indication, frailty, comorbidities, risks and benefits.
Verbatim wording from the response “This guidance and that contained in the GIRFT 2021 report reflects the BSG view that thresholds should not be set on the basis of age alone (nor indeed that patients are discriminated against on the basis of their age) but rather should be part of a wide-ranging assessment of the patient. Factors to be considered would include both the strength of the indication for colonoscopy as well as individual patient risk factors.” Source location Response from British Society of Gastroenterology
Open published response
24 Mar 2025 Thomas Alexander GLOVER · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Failure to increase vigilance when patients with para-oesophageal hiatus hernia present with symptoms View source Lack of patient awareness of the increased risk of para-oesophageal hiatus hernia View source Lack of awareness among non-gastro specialist medical clinicians of para-oesophageal hiatus hernia and its additional risk View source Failure of NHS England online guidance to distinguish between hiatus hernia types View source See 1 more concern
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AI-generated summary
Thomas Alexander GLOVER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Glover died at Broomfield Hospital on 22 May 2024 after a delayed presentation of a strangulated hiatus hernia with an ischaemic stomach, followed by emergency surgery, multi-organ failure and end-of-life care. The report identified a missed opportunity for earlier diagnosis after his discharge from Ipswich Hospital, and raised concerns about limited awareness among NHS clinicians of the differing risks associated with para-oesophageal hiatus hernias and the lack of distinction in NHS England guidance.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Failure to increase vigilance when patients with para-oesophageal hiatus hernia present with symptoms
Wider context from the report “4. As a result, the lack of understanding of the difference between the two types of hiatus hernia within the medical community means that there is no increased vigilance taken when individuals with a para-oesophageal hiatus hernia present with symptoms .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Lack of patient awareness of the increased risk of para-oesophageal hiatus hernia
Wider context from the report “5. In addition, the cohort of individuals who suffer from para-oesophageal hiatus hernia in England, are unaware of the increased risk posed by their condition and are therefore unable to advocate for more testing, or seek a second opinion when worrying symptoms do arise .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among non-gastro specialist medical clinicians of para-oesophageal hiatus hernia and its additional risk
Wider context from the report “2. However, it was heard in evidence that in England many non-gastro specialist medical clinicians within the NHS are unaware of the difference in the two types of hiatus hernia , and are therefore unaware of the additional risk posed to the 5-15% of patients with a para-oesophageal hiatus hernia .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS England online guidance to distinguish between hiatus hernia types
Wider context from the report “3. It was heard in evidence that the NHS England online guidance makes no distinction between the two types of hiatus hernias , whereas the guidance for NHS Scotland does.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Guts UK to develop a patient information leaflet on hiatus hernia and complications, emphasising vigilance after para-oesophageal hernia diagnosis.
Verbatim wording from the response “Whilst The Society is not a patient-facing Charity, we will work with Guts UK, a national charity for the digestive system, to develop a patient information leaflet for hiatus hernia, highlighting the need for extra vigilance following diagnosis of a para-oesophageal hernia.” Source location Response from The British Society of Gastroenterology
Open published response
11 Oct 2024 Kingsley Efosa Imafidon · Prevention of Future Deaths report North London
View report summary
Concerns raised 4 Lack of consideration of additional post-operative monitoring and requirements for patients with HbSS View source Failure of the elective liver biopsy SOP to account for patients with other pathologies such as HbSS View source Lack of liaison between care teams about HbSS-relevant matters before liver biopsy View source Failure of liver biopsy clinical guidelines to provide guidance for patients with other pathologies such as HbSS View source See 1 more concern
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AI-generated summary
Kingsley Efosa Imafidon · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kingsley Efosa Imafidon, who had homozygous sickle cell disease and suspected liver cirrhosis, underwent a liver biopsy on 29 November 2023. He was found unresponsive at home on 2 December 2023, and the post-mortem examination found extensive fresh haemorrhage into the peritoneal cavity following the biopsy. The concerns included lack of apparent liaison about the relevance of his sickle cell disease, insufficient consideration of additional monitoring, and gaps in the biopsy guidance and procedure for patients with conditions such as HbSS.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Lack of consideration of additional post-operative monitoring and requirements for patients with HbSS
Wider context from the report “• There was no apparent liaison between the teams involved in Kingsley's care to consider any matters that may be relevant to his HbSS prior to the biopsy being carried out;
• The Trust’s Standard Operating Procedure (“SOP”) for Elective Liver Biopsy does not appear to give consideration to patients with other pathologies such as HbSS;
• There was no apparent consideration given to potential additional post-operative monitoring or requirements for a patient with HbSS ;
• The Trust’s SOP refers to a document titled “Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology” (Neuberger J, Patel J, Caldwell H et al. Gut 2020) which provides advice on liver biopsy techniques, methods and aftercare etc. These guidelines do not appear to give consideration (and therefore guidance) in relation to the use of liver biopsy for patients with other pathologies such as HbSS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Failure of the elective liver biopsy SOP to account for patients with other pathologies such as HbSS
Wider context from the report “• There was no apparent liaison between the teams involved in Kingsley's care to consider any matters that may be relevant to his HbSS prior to the biopsy being carried out;
• The Trust’s Standard Operating Procedure (“SOP”) for Elective Liver Biopsy does not appear to give consideration to patients with other pathologies such as HbSS ;
• There was no apparent consideration given to potential additional post-operative monitoring or requirements for a patient with HbSS;
• The Trust’s SOP refers to a document titled “Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology” (Neuberger J, Patel J, Caldwell H et al. Gut 2020) which provides advice on liver biopsy techniques, methods and aftercare etc. These guidelines do not appear to give consideration (and therefore guidance) in relation to the use of liver biopsy for patients with other pathologies such as HbSS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Lack of liaison between care teams about HbSS-relevant matters before liver biopsy
Wider context from the report “• There was no apparent liaison between the teams involved in Kingsley's care to consider any matters that may be relevant to his HbSS prior to the biopsy being carried out ;
• The Trust’s Standard Operating Procedure (“SOP”) for Elective Liver Biopsy does not appear to give consideration to patients with other pathologies such as HbSS;
• There was no apparent consideration given to potential additional post-operative monitoring or requirements for a patient with HbSS;
• The Trust’s SOP refers to a document titled “Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology” (Neuberger J, Patel J, Caldwell H et al. Gut 2020) which provides advice on liver biopsy techniques, methods and aftercare etc. These guidelines do not appear to give consideration (and therefore guidance) in relation to the use of liver biopsy for patients with other pathologies such as HbSS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Failure of liver biopsy clinical guidelines to provide guidance for patients with other pathologies such as HbSS
Wider context from the report “• There was no apparent liaison between the teams involved in Kingsley's care to consider any matters that may be relevant to his HbSS prior to the biopsy being carried out;
• The Trust’s Standard Operating Procedure (“SOP”) for Elective Liver Biopsy does not appear to give consideration to patients with other pathologies such as HbSS;
• There was no apparent consideration given to potential additional post-operative monitoring or requirements for a patient with HbSS;
• The Trust’s SOP refers to a document titled “Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology” (Neuberger J, Patel J, Caldwell H et al. Gut 2020) which provides advice on liver biopsy techniques, methods and aftercare etc. These guidelines do not appear to give consideration (and therefore guidance) in relation to the use of liver biopsy for patients with other pathologies such as HbSS .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish advice on biopsy precautions for patients with blood disorders in a peer-reviewed journal within three months.
Verbatim wording from the response “We would therefore agree that it is important to remind health care professionals that particular care must be taken in any patients with a prior history of blood disorders before any biopsy. We would encourage discussion with a consultant haematologist for anyone with any blood disorder that may predispose to extra bleeding such as sickle cell disease.” Source location Response from BSG
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish advice on biopsy precautions for patients with blood disorders in the BSG newsletter within one month.
Verbatim wording from the response “We would therefore agree that it is important to remind health care professionals that particular care must be taken in any patients with a prior history of blood disorders before any biopsy. We would encourage discussion with a consultant haematologist for anyone with any blood disorder that may predispose to extra bleeding such as sickle cell disease.” Source location Response from BSG
Open published response
Concerns raised 1 Failure of anticoagulation guidance to address patients with coronary stents undergoing therapeutic endoscopy while taking a single anticoagulant View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Terence William SULLIVAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Terence Sullivan underwent surgery to remove a sigmoid colon polyp on 8 August 2023, after temporarily stopping rivaroxaban. He suffered an acute myocardial infarction caused by blockage in a coronary artery stent and died in hospital on 10 August 2023. The principal concern was that NICE and BSG guidance may not reflect best practice for patients with coronary stents taking a single anticoagulant who require therapeutic endoscopy, including whether pre-operative consultation with an interventional cardiologist is needed.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Failure of anticoagulation guidance to address patients with coronary stents undergoing therapeutic endoscopy while taking a single anticoagulant
Wider context from the report “Since June 2023, Mr. Sullivan had been on a single anticoagulant medication ( Rivaroxaban ) to prevent previously inserted coronary stents from blocking. The clinicians who carried out the endoscopic procedure on 8.8.23, however, ensured that he had not taken any Rivaroxaban for the previous 48 hours. This was in accordance with Worcestershire Acute Hospital NHS Trust ( WAHT )’s own guidance, itself based on NICE guidance “NICE Clinical Scenario: Rivaroxaban for a therapeutic endoscopy”. I also heard evidence that the equivalent guidance from the British Society of Gastroenterology ( BSG ) provided similar advice.
At inquest, I heard evidence from WAHT’s Clinical Director for Critical Care that none of the aforementioned guidance considered the specific, and increasingly more common, scenario of a patient with coronary stents who is on a single ( as opposed to more than one ) anticoagulant medication, and who requires a therapeutic endoscopic procedure. The Clinical Director felt that in those specific circumstances, best practice requires pre-operative consultation with an interventional cardiologist, to decide on the best anticoagulation strategy during the procedure.
I am concerned to hear that current guidance on this specific issue from both NICE and BSG may not now reflect current best practice.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue interim anticoagulation and coronary-stent safety guidance to all BSG members.
Verbatim wording from the response “At that time the published evidence did not support sole therapy with a DOAC for patients with coronary stents and atrial fibrillation, but it is apparent that this is now a more common scenario, and is indeed supported by European cardiology guidelines. I took advice from the cardiology co-author on the 2021 guidelines, ████████, who was aware of a similar case, and we plan to issue the following statement to all BSG members:” Source location Response from British Society of Gastronterology
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the interim anticoagulation and coronary-stent safety guidance as a peer-reviewed journal letter.
Verbatim wording from the response “We also plan to publish this guidance as a journal letter prior to a formal update of the BSG/ESGE guideline.”” Source location Response from British Society of Gastronterology
Open published response
Concerns raised 2 Lack of a formal system for surgeons to provide endoscopists with information about tumour localisation errors and tattooing problems View source Failure to require or recommend equipment that increases tumour localisation accuracy in routine colonoscopies View source
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AI-generated summary
Anne BRADLEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anne Bradley underwent a colonoscopy that identified and tattooed a tumour, but the tumour was not located where expected during colectomy, requiring removal of a further section of colon. Post-operative complications led to bowel ischaemia and her death. Concerns included the lack of routine use of equipment that could improve tumour localisation and the absence of a formal system for sharing information about incorrect localisation or tattooing problems with endoscopists.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal system for surgeons to provide endoscopists with information about tumour localisation errors and tattooing problems
Wider context from the report “(2) Feedback to endoscopists at St Richards Hospital
I heard evidence that at St Richards Hospital surgeons do not necessarily feedback information regarding tattooing problems or incorrect localisation of tumours to endoscopists .
The concern that I therefore have is that there is no formal system at St Richards Hospital which requires surgeons to provide information about the incorrect localisation of tumours or tattooing problems which is then shared with endoscopists .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Failure to require or recommend equipment that increases tumour localisation accuracy in routine colonoscopies
Wider context from the report “(1) Use of scope guides/scope pilots
The colonoscopy was carried out without the use of a scope guide or scope pilot as none were available in the room used for Anne Bradley’s procedure. A scope guide or scope pilot is an additional piece of equipment which assists the endoscopist in carrying out a colonoscopy. I heard evidence from the endoscopist and 3 consultant colorectal surgeons who all agreed that the use of scope guides or scope pilots assist in accurately recording the location of a tumour.
The accuracy of this information is important in assisting the surgeons to locate the tumour especially during laparoscopic (keyhole) surgery with early stage tumours. I heard evidence that there are limited markers within the colon to assist the endoscopist to know the location and that tattoos used to mark the location of a tumour can, and in this case did, pierce through the colon and mark multiple areas.
Whilst St Richards Hospital explained that they have now equipped all rooms with scope guides or scope pilots I heard that use of such equipment is not required by quality assurance organisations.
The concern I have is that equipment which increases the accuracy of the localisation of a tumour is not required or recommended for use in routine colonoscopies.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation MEI does not precisely localise tumours, so mandatory use would overstate its utility for precise lesion localisation.
Verbatim wording from the response “4. An MEI, does not provide precise localisation of a tumor as appears to have been suggested. MEIs can certainly help to negotiate a difficult colon, they can demonstrate if loops are formed in the scope and whether they have been removed, and for these reasons, MEIs are invaluable in training and also improve comfort for the patient. In the case of bowel cancer screening, where patients are voluntary and asymptomatic, MEIs have been extensively used to ensure the maximum success rate in visualising the whole colon. Their use in bowel cancer screening, however, was not primarily to provide a precise localisation of polyps or tumors which is why tattoos are extensively applied.” Source location 2021-0214-Response-from-British-Society-of-Gastroenterology_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandatory MEI use would create substantial manufacturer-compatibility and cost constraints without a clear benefit in every case.
Verbatim wording from the response “9. MEIs are manufacturer specific, so the “Scope Guide” will only work with Olympus scopes and “Scope Pilot” with Pentax scopes. Many units use Fujinon scopes, and whilst there was a similar system available in the past I am not aware at present whether it is still marketed. Mandating the statutory use of MEI effectively sanctions compulsory purchase without any competition, and might preclude a number of other commercial companies that manufacture scopes. The cost of an MEI is very significant, and therefore a mandatory obligation that they should be used in all cases could run into a cost of millions of pounds without there being a clear benefit in all cases.” Source location 2021-0214-Response-from-British-Society-of-Gastroenterology_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Published evidence-based guidelines do not support compulsory MEI use in all colonoscopies.
Verbatim wording from the response “6. A paper by ████████ et al. Colonic tumour localization using an endoscope positioning device. Eur J Gastroenterol Hepatol 2011;23:488-9, did suggest that MEI can improve accuracy of location to the correct segment of bowel, but as far as we are aware compulsory use of MEI in all colonoscopy is not recommended by any published evidence based guidelines because as many other factors, as we have indicated, can have a bearing on tumour localisation in an individual case.” Source location 2021-0214-Response-from-British-Society-of-Gastroenterology_Published
Open published response
Concerns raised 2 Absence of a national safety-netting system for biliary stents View source Failure of clinical guidance to define ‘short term’ for biliary stent use View source
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AI-generated summary
Stephen Whitehead · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Whitehead was admitted with abdominal symptoms on 6 February 2018 and deteriorated despite intensive treatment, dying in hospital on 8 February 2018. The report identified concerns about the absence of a national registry or safety-netting system for biliary stents and the lack of a clear definition of “short-term” use in clinical guidance.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Absence of a national safety-netting system for biliary stents
Wider context from the report “1. The absence of a national ‘safety-netting’ system (stent registry) , akin to that already established for ureteric stents (a web-based registry). There is no equivalent for biliary stents . Without a safety netting system, I am concerned that there is a real risk that patients will remain susceptible to what is medically recognised as the ‘phenomenon of the forgotten biliary stent’, resulting in future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical guidance to define ‘short term’ for biliary stent use
Wider context from the report “2. Definition of ‘short-term’ in clinical guidance - during the course of the evidence I heard that National Guidelines on the management of common bile duct stones currently indicates that the short term use of endoscopic biliary stents followed by further ERCP (or surgery) is an established and safe management option. However, the guidelines do not provide an operational definition of ‘short term’ . It is therefore unclear as to what is ‘safe’ in terms of timeframe .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss adding stent planning and recall databases to national endoscopy standards key performance indicators and incorporating them into the ISREE programme.
Verbatim wording from the response “The BSG and JAG are however in discussion concerning adding the use of a stent planning/recall database to the key performance indicators (KPI) within its national standards framework, and incorporating it into the ISREE (Improving Safety and reducing Errors in Endoscopy) programme. This topic will be formally discussed at the BSG Endoscopy Committee in October.” Source location 2018-0293-Response-by-BSG
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recording and monitoring biliary stents should be owned by the endoscopy unit that inserted the stent.
Verbatim wording from the response “3. Database of stents. We completely agree that a clear record of when a stent has been placed, and when this should be removed or changed, is important. We feel this should be within the ownership of the endoscopy unit that has inserted the stent. This may be a formal database or a facility within the electronic endoscopy reporting tool, but should be contemporaneously entered at the time of the ERCP, with a clear plan as to timeframe for patient review/repeat procedure. Crucially the system should allow easy, rapid and demonstrable review of all patients who have undergone stenting within an extended time period.” Source location 2018-0293-Response-by-BSG
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A national biliary stent database is not needed because local endoscopy-unit arrangements and communication address the identified shortcomings.
Verbatim wording from the response “After careful consideration, we do not feel that the answer is a national database of biliary stents. This would be unwieldy and require significant additional manpower and infrastructure to police. The vast majority of patients will have their care in one locality and, as suggested in the report, shortcomings in local arrangements of care, including communication between local teams, GP and patient, were the fundamental issues highlighted here. Although the National Endoscopy Database (NED) has now been introduced nationally, it is important to record that this does not allow individual patient tracking, and could not act as a proxy database of biliary stents.” Source location 2018-0293-Response-by-BSG
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A national biliary stent database is not pursued because it would be unwieldy and require significant additional manpower and infrastructure.
Verbatim wording from the response “After careful consideration, we do not feel that the answer is a national database of biliary stents. This would be unwieldy and require significant additional manpower and infrastructure to police. The vast majority of patients will have their care in one locality and, as suggested in the report, shortcomings in local arrangements of care, including communication between local teams, GP and patient, were the fundamental issues highlighted here. Although the National Endoscopy Database (NED) has now been introduced nationally, it is important to record that this does not allow individual patient tracking, and could not act as a proxy database of biliary stents.” Source location 2018-0293-Response-by-BSG
Open published response
14 Jan 2014 Craig Adam White · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 4 Failure to provide continuing patient education about Infliximab treatment risks View source Delays in initiating treatment when tuberculous meningitis is suspected View source Lack of protocols for pre-Infliximab tuberculosis screening View source Lack of healthcare professional awareness of the increased tuberculosis risk inherent in Infliximab treatment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Craig Adam White · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Craig Adam White was a 21-year-old student who developed disseminated tuberculosis, including tuberculosis leptomeningitis, while receiving immunosuppressive treatment for Crohn’s disease. He had recurrent chest infections and later deteriorated with neurological illness before tuberculosis was confirmed. The principal concerns were tuberculosis screening before Infliximab treatment, healthcare professionals’ awareness of the associated risk, continuing patient education, and prompt treatment when tuberculous meningitis is suspected.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuing patient education about Infliximab treatment risks
Wider context from the report “3 The need for continuing patient education about the risks of Infliximab treatment
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Delays in initiating treatment when tuberculous meningitis is suspected
Wider context from the report “4 The need for prompt treatment to be initiated when tuberculous meningitis is suspected
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols for pre-Infliximab tuberculosis screening
Wider context from the report “1 Protocols for pre-Infliximab treatment screening for tuberculosis
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society Of Gastroenterology; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare professional awareness of the increased tuberculosis risk inherent in Infliximab treatment
Wider context from the report “2 Awareness of Health Care Professionals, in particular prescribers of the increased risk of TB inherent Infliximab treatment
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations