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The patient had a medical history of ulcerative colitis and a positive family history of colon cancer. He received regular colonoscopies with documentation of pseudopolyps in both 2013 and 2014.

Eight pathology specimens were collected during a colonoscopy in 2016. Seven of them were interpreted as clearly benign. The eighth specimen was found to be “indefinite for dysplasia.” The gastroenterologist did not notice the troubling pathology nor do the records make any mention of it. In fact, a letter was written indicating that the results of recent evaluations had all been normal.

The patient was not seen again until two years later in June of 2018 for a routine clinic visit where it is noted that the patient had “Ulcerative colitis, unspecified, without complications," with recommendation for a colonoscopy one year from the date of that appointment. The gastroenterologist noted that the patient was “doing well in remission.” The patient was sent a form letter in August of 2019 stating he was due for a colonoscopy, but it was never scheduled.

Over the ensuing years, the patient complained of increased symptoms.

He was eventually hospitalized in 2021, complaining of worsening abdominal pain, nausea, and vomiting. A CT scan was performed that noted possible malignancy as well as metastasis.

While the patient was hospitalized he underwent an open total colectomy with end ileostomy, resulting in the unfortunate diagnosis of metastatic colon cancer. The patient’s colon cancer was preventable and earlier treatment would likely have been curative.


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