“He’s been having blood when he goes — but he gets so anxious about the doctor’s”

This is the ADJUSTED CONSULTATION done well. Communicate directly WITH the patient — here Danny, who has Down’s syndrome and a learning disability — in short plain language at his pace, using the support worker to facilitate rather than replace his voice, and providing reasonable adjustments (longer appointment, quiet space, easy-read information, a familiar person), which are a legal duty under the Equality Act. The cardinal error to avoid is DIAGNOSTIC OVERSHADOWING: attributing new physical symptoms to the learning disability or to anxiety/behaviour. Rectal bleeding, change in bowel habit and weight loss are physical symptoms to be taken exactly as seriously as in anyone — arguably more so, given the stark health inequalities and premature mortality faced by people with learning disabilities. His symptoms meet the FIT criteria of NICE NG12 (Suspected cancer: recognition and referral, last updated April 2026) and NICE HTG690, which make colorectal referral FIT-first: FIT for a change in bowel habit at any age, and at 50+ for unexplained rectal bleeding, abdominal pain or weight loss (IDA and an abdominal mass are FIT indications too); FIT ≥10 µg Hb/g → suspected cancer pathway referral (the NHS England Faster Diagnosis Standard aims to confirm or rule out cancer within 28 days of referral); only a rectal or anal mass or anal ulceration is referred without FIT. Examine face to face — not by video — (abdomen ± DRE if consented and tolerated), and check FBC/ferritin, TFTs and coeliac serology (NICE NG20; thyroid and coeliac disease are both commoner in Down’s syndrome). Assess CAPACITY for each specific decision under the Mental Capacity Act — presume it, support it, and only if a specific decision-making capacity is lacking act in best interests with consultation, documenting the process; capacity is decision-specific and never assumed absent because of the disability. Crucially, make the investigation ACCESSIBLE — flag reasonable adjustments and a hospital passport, plan for bowel prep/procedure and anxiety, and actively track the referral — because health inequality lives in the logistics, and a referral the patient cannot navigate is not care.