Joint Advisory Group on Gastrointestinal Endoscopy

Private and voluntary organisations · Health professional committee

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First report 20 Jun 2021•Latest report 20 Jun 2021

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Joint Advisory Group on Gastrointestinal Endoscopy linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West Sussex

    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.

    Read the report on judiciary.uk

    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 Joint Advisory Group on Gastrointestinal Endoscopy; 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 Joint Advisory Group on Gastrointestinal Endoscopy; 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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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026