PFD report

Vivian Joan Tuddenham NOLAN · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 5 Nov 2025•Teesside and Hartlepool

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Lack of clinician knowledge about the increased risks of diagnostic colonoscopies in the 80+ age group
  2. Lack of clinical guidance on the increased risks of diagnostic colonoscopies in the 80+ age group
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Publicise the guidance to members through newsletters, podcasts and webinars.

    Stated by British Society Of GastroenterologyStated completedThe respondent said that this action was complete when they made their response on 7 November 2025.
  2. Action

    Publish guidance on individualised consent and diagnostic colonoscopy selection for patients with frailty or limited life expectancy.

    Stated by British Society Of GastroenterologyStated completedThe respondent said that this action was complete when they made their response on 7 November 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Published guidance and publicity provide sufficient awareness of increased colonoscopy risks; there is no evidence clinicians are failing to consider relevant factors.

    Stated by British Society Of GastroenterologyExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

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
Page 2 · response
Published 7 November 2025

Open published response

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
Page 1 · response
Published 7 November 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

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
Page 2 · response
Published 7 November 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

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
Page 2 · response
Published 7 November 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Recommendations in the United States and Europe are understood to support individualised colonoscopy decisions, rather than a higher clinical threshold.

    Stated by British Society Of GastroenterologyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    The Association of Coloproctology may be better placed to raise awareness among colorectal surgeons who perform colonoscopy.

    Stated by British Society Of GastroenterologyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Recommendations in the United States and Europe are understood to support individualised colonoscopy decisions, rather than a higher clinical threshold.

Verbatim wording from the response

“We note the suggestion that there is a higher clinical threshold in other countries. Our understanding is that recommendations from other health systems (USA and Europe) are similar to that in the UK in that any decision to undertake a colonoscopy should be individualised to the patient. If you are aware of evidence to the contrary, then we would be happy to review it.”

Source location

Response from British Society of Gastroenterology
Page 2 · response
Published 7 November 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

The Association of Coloproctology may be better placed to raise awareness among colorectal surgeons who perform colonoscopy.

Verbatim wording from the response

“The Coroner may be minded to also seek the opinion of the Association of Coloproctology of Great Britain and Northern Ireland (ACPGBI) whose members mainly comprise colorectal surgeons who also carry out colonoscopy, should he consider that raising awareness amongst this group of practitioners would be best served here.”

Source location

Response from British Society of Gastroenterology
Page 2 · response
Published 7 November 2025

Open published response
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026