[2025] EWHC 2025 (KB)

A referral letter dated 7 March 2019 was sent by the GP (Dr Siew) to the defendant. The letter stated (of relevance) that the claimant “reports a 4-month history of fresh red painless bleeding with each defecation. This has not improved with time. She also reports an associated abdominal pain with this. She tells me that she has existing haemorrhoids.” The letter stated “Her bowel habits are unchanged tending to be more slow, but no hard stools. She opens her bowels every 2 days or so. She has not noticed any weight loss, but says she has some decreased appetite.” Regarding the GP’s examination, the letter stated, “Examination: External haemorrhoids + potential bleeding point seen. No active bleeding. No rectal mass.” The letter requested, “in view of her ongoing bleeding and abdominal pain, I would be grateful for your opinion.”

Of note, in neither the claimant’s witness statement nor in evidence, did the claimant refer to having been diagnosed with haemorrhoids or of being aware that she had external haemorrhoids.

In her witness statement, the claimant denied telling the GP that she had existing haemorrhoids. She said in her witness statement that all she told him was that she had a skin tag in this area. She said that she wasn’t aware of, and had not previously felt, any “acutely present external haemorrhoids” – which she described as being “unusually large/bulging or exposed bulky tissue that I might have expected to be hanging outside my bottom. I didn’t have any pain either that I would supposedly associate with having what is described as ‘external piles’. I was only aware of my skin tag. To me, external haemorrhoids would give a picture of something outside of my rectum, resembling grapes. That was not something I was suffering with.” She said that the GP carried out a brief internal examination and told her he could feel some haemorrhoids which might be the cause of the bleeding.

In cross-examination, she said that she did not have any pain that she would have associated with external haemorrhoids. She denied having haemorrhoids that hung outside her anus. She said that she had not confused haemorrhoids with a skin tag. She said that the skin tag was “tiny and fleshy” and she would have expected haemorrhoids to be larger than this. She said that there may have been some tinier skin tags surrounding it, but she could only feel one. She suggested that a GP would refer to any kind of skin tag as a haemorrhoid. The experts agree with this as their Joint Statement states that GPs tend to use the terms ‘piles’ or ‘haemorrhoids to describe anything wrong with the anus, particularly if associated with itching or bleeding. The defendant in cross-examination also agreed that GP’s often misuse or misapply the term “haemorrhoids”.

Mr Thompson agreed in evidence that if the GP’s examination was correct then this must mean that the claimant’s haemorrhoids were Grade 3 or 4 although both experts agreed in their Joint Statement that a surgeon’s classification would be more generally accepted than a GPs. The defendant agreed that his examination of the patient would be more in depth than an examination conducted by a GP.

It was put to the claimant in cross-examination, that Mr Thompson’s report dated 4 February 2022, states that during her zoom meeting with him on 29 December 2021 she said that “she had no anal pain but was aware of a small external skin nodule which made cleaning difficult after a bowel action. She was not aware of any prolapse although she was aware of something around the anus once every two weeks when she had to strain to empty her bowels. This swelling had not occurred since the haemorrhoidectomy”. She said that Mr Thompson’s account was not accurate and that she did not tell him this because she did not have swelling, she only had discomfort and nothing else apart from the skin nodule. The same passage from the report was put to Mr Thompson in cross-examination. He did not resile from his record of what the claimant told him but said that her account was consistent with swelling in the perianal area which does not mean that it was outside the anus. However, he then also agreed a responsible body of Consultant Colorectal Surgeons would consider this information to be consistent with a grading of 2 – 3.

The GP (Dr Siew) was not called as a witness by either party so the inconsistencies between his referral letter and the claimant’s recollection could not be put to him.