The Association of Coloproctology of Great Britain and Ireland

Private and voluntary organisations · Health professional body

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First report 20 Jun 2021•Latest report 23 Apr 2025

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
2

Naming this recipient

Published responses
50%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
1

Described in responses

Concerns and recipient responses

Statements from The Association of Coloproctology of Great Britain and Ireland linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Berkshire

    AI-generated summary

    Lorraine Sandra Parker · 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

    Lorraine Parker underwent surgery for sigmoid colon cancer in January 2024 and was discharged with a rising CRP and no post-operative scan. After returning to hospital, an anastomotic leak was initially missed, and she later died at Royal Berkshire Hospital on 30 March 2024 following a sudden deterioration. The principal concerns were the lack of guidance requiring consideration of CT scanning when CRP is high and rising or not decreasing, and reliance on clinical judgement without sufficiently accounting for objective blood-test results.

    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 The Association of Coloproctology of Great Britain and Ireland; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to take postoperative CRP results into account in discharge and scanning decisions

    Wider context from the report

    “2. There is currently no guidance which requires surgeons to consider scanning for patients who have undergone major abdominal surgery and whose CRP is high and not decreasing, as was the case here at the time Lorraine was discharged from hospital on 31st January 2024. 3. There may be some difficulty in creating a hard line requirement for CT scanning based on a particular CRP result, but I am concerned that there is no guidance in place for requiring a consultant to consider this – perhaps when the CRP is above a certain figure and either not decreasing or continuing to rise. Any such guidance could still allow for clinical judgement – and documenting of the reasons for that decision. 4. It is my experience that clinical judgement alone, particularly where a patient looks well “from the end of the bed” is not always sufficient in this scenario. I have seen a number of avoidable death cases in this context. The purpose of blood test results is to flag up objective areas of concern. There is much reference to chasing up CRP results in Lorraine’s records, but these do not appear to have been taken into account at the time that she was discharged from the hospital without a post-operative scan. ”
    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 The Association of Coloproctology of Great Britain and Ireland; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of guidance requiring consideration of CT scanning when CRP is high and not decreasing or rising after major abdominal surgery

    Wider context from the report

    “2. There is currently no guidance which requires surgeons to consider scanning for patients who have undergone major abdominal surgery and whose CRP is high and not decreasing, as was the case here at the time Lorraine was discharged from hospital on 31st January 2024. 3. There may be some difficulty in creating a hard line requirement for CT scanning based on a particular CRP result, but I am concerned that there is no guidance in place for requiring a consultant to consider this – perhaps when the CRP is above a certain figure and either not decreasing or continuing to rise. Any such guidance could still allow for clinical judgement – and documenting of the reasons for that decision. 4. It is my experience that clinical judgement alone, particularly where a patient looks well “from the end of the bed” is not always sufficient in this scenario. I have seen a number of avoidable death cases in this context. The purpose of blood test results is to flag up objective areas of concern. There is much reference to chasing up CRP results in Lorraine’s records, but these do not appear to have been taken into account at the time that she was discharged from the hospital without a post-operative scan. ”
    Open source report

    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

    Provide existing guidance on postoperative CRP monitoring and CT investigation triggers.

    Verbatim wording from the response

    “In relation to the matters of concern raised, I attach Issues in Professional Practice Guidance on the Prevention, Diagnosis and Management of Colorectal Anastomotic Leak, produced in collaboration with ACPGBI. Although published in 2016, the guidance around post-operative CRP monitoring and triggering subsequent radiological investigation remains as pertinent to clinical practice now as it was then. Please see in particular pages 16-17, where cut off values for CRP triggering a subsequent CT scan are also considered. In addition, there have been several subsequent publications (available on Pubmed) confirming this practice.”

    Source location

    Response from The Association of Coloproctology of Great Britain and Ireland
    Page 1 · response
    Published 24 April 2025

    Open published response

    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

    Existing guidance on CRP monitoring and CT investigation makes further ACPGBI guidance unnecessary at this time.

    Verbatim wording from the response

    “In relation to the matters of concern raised, I attach Issues in Professional Practice Guidance on the Prevention, Diagnosis and Management of Colorectal Anastomotic Leak, produced in collaboration with ACPGBI. Although published in 2016, the guidance around post-operative CRP monitoring and triggering subsequent radiological investigation remains as pertinent to clinical practice now as it was then. Please see in particular pages 16-17, where cut off values for CRP triggering a subsequent CT scan are also considered. In addition, there have been several subsequent publications (available on Pubmed) confirming this practice.”

    Source location

    Response from The Association of Coloproctology of Great Britain and Ireland
    Page 1 · response
    Published 24 April 2025

    Open published response

  2. 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 The Association of Coloproctology of Great Britain and Ireland; 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 The Association of Coloproctology of Great Britain and Ireland; 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