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Warning lives are being put at risk by delays in providing bowel care to spinal patients


An alert has been issued to the NHS in England after concerns were raised about patients with spinal injuries facing delays in receiving specialist care to clear their bowels.

Such delays can result in a brain haemorrhage, high blood pressure, extreme discomfort and ultimately death, warned the patient safety alert issued this week by NHS Improvement.

“We are urging the NHS to take immediate action”

Kathy McLean

Reasons for the delay cited by the regulator included lack of staff training, confusing local policies and the belief that digital removal of faeces represented assault.

The alert highlighted that most patients requiring specialist bowel care have lost their ability to clear their bowels on their own following spinal injuries or because of a long-term neurological illness.

But the regulator has received 61 reports over the past four and a half years of hospital patients not getting specialist bowel treatment quickly enough to ensure their regular routine continued.

The reports included three incidents of autonomic dysreflexia – a life-threatening condition that can happen to those who have injured their spinal cord or upper back. It is characterised by dangerous spikes in blood pressure which can lead to cardiac arrest, stroke, brain haemorrhage and even death.

In the alert, one patient said: “Despite explaining my situation, I had to wait eight days for an enema. I’d had shoulder surgery so couldn’t do it myself. I had the beginnings of autonomic dysreflexia.”

NHS Improvement concluded that more training and experience among NHS staff was needed outside of specialist injuries units for how to provide bowel care.

The regulator also identified a number of issues that needed action across the NHS, with the exception of specialist spinal injury and community heath teams.

“Despite explaining my situation, I had to wait eight days for an enema”


It found unclear local policies stating who could undertake digital removal of faeces, including the patient’s own carers or health professionals from another provider.

It also found a lack of knowledge of relevant clinical guidance, uncertainty over requirement and provision of training and uncertainty over using alternative methods of bowel management.

The regulator also noted that there was a “mistaken belief that this type of care constituted assault”.

NHS Improvement is now calling on providers of NHS care to “take action to ensure that these patients are given the potentially life-saving care they need”.

Trusts have been asked to review bowel care guidance and develop an action plan within the next six months outlining how they will ensure spinal injury patients receive bowel care in a “timely manner”.

To support this, NHS England has published new guidance to help address any confusion on when patients should receive this treatment, who is required to provide it and how this should be given.

Dr Kathy McLean, NHS Improvement’s executive medical director and chief operating officer, said: “We know patients with spinal injuries who need care from teams unfamiliar with their needs are waiting too long to receive the vital bowel care they need.

“The failure to provide this care can cause a dangerous reaction, including rapid rising blood pressure, which can put patients’ lives at risk,” said Ms McLean.

“We are urging the NHS to take immediate action to ensure staff are aware of the importance of maintaining patients’ normal bowel routine and know how to get support from colleagues with specialist skills whenever they need it,” she said.

She added: “This not only keeps patients safe but ensures that they are treated with the care and dignity they deserve.”

“This represents a significant step forward in driving standards of care for spinal care injuries”

Rupert Earl

Meanwhile, the Spinal Injuries Association has surveyed its 10,000 members and found that 49% of them had not been given bowel care while in hospital.

The charity also found that 41% of all trusts did not run courses to train their staff in manual bowel care removal techniques.

Dr Rupert Earl, chair of association, welcomed the publication of the alert. He said: “This represents a significant step forward in driving standards of care for spinal care injuries people across the NHS.

“Our members frequently tell us of their bad experiences of the bowel care they receive in non-specialist settings – and the life-threatening implications of poor care,” he said.

He added: “We look forward to working further with NHS Improvement to ensure that appropriately trained staff, as well as the appropriate policies, guidelines and oversight process are all in place.”


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Readers' comments (3)

  • I am an RN and I taught bowel care to support workers who delivered packages of care to enable spinal patients to fulfil their aspirations out in the community - I can't tell you how straight forward it was - there is up to date guidance on the care of the neurogenic bowel that details the A&P, the procedures, the legalities and meaning of 'consent'. What happened was if our patients/clients were hospitalised (for anything) they would end up being put into Autonomic Dysreflexia and being made unwell and miserable because 'proper' hospital nurses were incapable of giving what for them was 'basic care' of their bladder and bowels. I trained the support workers on a prosthetic 'bottom' and they had a competency to work through. This is not complicated and knowing how ward nurses look down on 'support' staff and those of us not in the NHS - it's a little bit pathetic - also the support workers offered to go into hospital with their client (because surprise they really cared about them) and carry out bowel care but they weren't allowed - what was allowed for the client to end up miserable and frustrated and the potential stigma of neurogenic bowel management amplified beyond reason ! Sort yourselves out - my moan is not for Nurses in specialist spinal units they are fab.

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  • I am horrified to read this. Having taught so many nurses and carers bowel care for spinal patients why are staff now so ill informed?
    I have seen this for myself recently when my daughter had spinal surgery within a London teaching hospital she was sent home without anyone checking her bowel activity. Result- urgent readmission and the involvement of the colorectal team. In 2018??
    People sneer at the words basic nursing care, I have always taught it as essential nursing care. The nursing profession should think carefully about academia versus care instead of the two working seamlessly together.

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  • Dear anonymous
    please don't generalise that 'proper hospital nurses'!!, 'look down' on support staff and 'those not in the NHS' as this is not the case, your comments are divisive and unnecessary.
    Having worked myself as both support staff and outside of the NHS in my 30+ years as a nurse (as have many nurses)both are an integral and essential part of healthcare, its up to everyone to work together and promote professionalism and safe standards of care and competence, whatever your background, grade or employer.

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