The size of the cannula used for Mrs O’s surgery
16. Mrs O says the Trust should have used a smaller cannula for her surgery.
17. In its response, the Trust says it used a large-bore cannula because of the type of surgery Mrs O underwent, which is major and complex. The Trust says the surgery is potentially dangerous because it can result in a lot of blood loss and fluid evaporation. The Trust says the large cannula allows over 250ml of blood per minute to be administered to the patient. A small cannula allows only 30-60mls per minute. The Trust says a large cannula was essential for safe, optimal patient care in these circumstances.
18. The Trust used a 14G cannula, which is 45mm long. To consider whether it was appropriate to use this, we have received clinical advice from our anaesthetist adviser and referred to the GMC guidance on treating patients effectively. Section 16b of this GMC guidance says doctors must provide effective treatments based on the best available evidence. Our anaesthetic adviser explained the surgery Mrs O had is associated with significant blood loss, so the use of the largest commonly available intravenous cannula was correct.
19. We have found the type of cannula the Trust used was clinically appropriate. We have not found a failing with this part of the complaint.
The Trust’s monitoring of the cannula
20. Mrs O says the Trust failed to check whether the cannula was working and staying in her vein. Mrs O says the Trust should have checked the cannula site regularly to ensure there was no fluid leaking out. Mrs O says if the Trust had done this the fluid would not have been able to leak into her surrounding tissue.
21. The Trust says the cannula site was under the surgical drapes and so the anaesthetist could not see it during the surgery. The Trust says the anaesthetist observed a reduction in flow through the cannula, which can show either a ‘kinking’ of the infusion line or a problem with the cannula. When the anaesthetist thought it was safe, they asked the surgeon to step back so they could access the cannula site and inspect it. At this point it became clear Mrs O’s arm was swollen, suggesting the fluid was leaking into the surrounding tissues (extravasation). The infusion of fluid was stopped and the cannula was moved to her left arm.
22. The Trust has accepted the cannula flow of IV fluid slowed shortly after 11.30am, but the infusion site was not inspected until 12.10pm, at which point her arm was swollen due to around 500ml of fluid extravasating (leaking from the cannula tip into tissues outside the relevant vessel). This means the Trust did not inspect the infusion site until 40 minutes after the first sign the flow of fluid through the IV drip into Mrs O’s vein may have decreased.
23. Section 2 of the NHS Tayside guidance explains extravasation of medications must be treated as a medical emergency and immediate action must be taken. It says early detection of extravasation is important in minimising damage and extravasation should be suspected if the infusion does not flow freely.
24. Our anaesthetist adviser says anaesthetists should inspect infusion sites regularly during surgery if possible. If this is not possible, as in Mrs O’s case because the cannula site was under surgical drapes, they should maintain a high level of suspicion there may be problems with the cannula and they should visually inspect the cannulation site if there is any possibility the flow may be impaired.
25. Based on the guidance and the clinical advice we have received, we have found the infusion site should have been visually inspected as soon as there was a suggestion the flow of the IV fluid was impaired, which was at 11.30am. There was a gap of 40 minutes between this point and the point when the Trust inspected the cannulation site. We have identified this to be a failing and we discuss the impact of this below.
Referral to a plastic surgeon
26. Mrs O says the Trust should have referred her to a plastic surgeon when it discovered extravasation had happened during her surgery. Mrs O says the Trust failed to do this and it would have been appropriate for a plastic surgeon to review her extravasation wounds after her surgery.
27. The Trust says Mrs O’s elbow area was reviewed by doctors and nurses on the ward and the clinical opinion was there was no need for a referral to tissue viability (a nurse-led speciality that considers all aspects of skin and soft tissue wounds, such as pressure ulcers, leg ulcers, and surgical wounds). The area on her right arm was regularly observed and her dressing was changed daily. The Trust says it did not have serious concerns about Mrs O’s arm immediately after the operation.
28. The Trust did not refer Mrs O to a plastic surgeon after she had suffered her extravasation injury on 21 July 2020. Mrs O was seen by a plastic surgeon in March 2021. The plastic surgeon’s letter says the Trust told the plastic surgeon the drugs that extravasated into Mrs O’s arm were fentanyl (a strong opioid painkiller used to treat severe pain, for example during or after an operation or a serious injury, or pain from cancer) and atracurium (a neuromuscular blocking agent widely used in anaesthesia) and the Trust did not consider either of these drugs to be particularly toxic to tissues. Hartmann’s solution (a clear, colourless solution used to restore fluid levels and the normal salt balance) was also extravasated into Mrs O’s arm.
29. Section 2 of NHS Tayside guidance says if extravasation happens the designated members of staff with enough experience of assessing extravasation injuries must be told immediately, in accordance with the contact list. Section 7 says treatment advice should always be asked for and the patient should be monitored closely. It says in the event of a more extensive extravasation, or the extravasation of a substance likely to cause a serious reaction, an urgent referral to the on-call plastic surgeon is essential.
30. St George’s Health Care NHS Trust’s ‘Critical Care Intravenous Drug Administration Guide’ says if fentanyl is extravasated, it may cause tissue damage. Tissue damage can include pain, stiffness and swelling.
31. In Mrs O’s clinical records, it was noted she had suffered blistering, indicating a threat to tissue viability. Our anaesthetic adviser says due to the volume of fluid and drugs that were likely to have been extravasated a plastic surgeon’s opinion should have been sought at the time blistering was observed.
32. Based on the guidance we have referred to and the clinical advice we have received, we have found it would have been clinically appropriate for the Trust to seek a plastic surgeon’s opinion on the extent of Mrs O’s extravasation injuries when her blisters were first observed. As the Trust did not do this, we have identified this to be a failing. We discuss the impact of this below.
The Trust’s communication with Mrs O’s husband after her surgery
33. Mrs O says when a doctor spoke to her husband after she was out of surgery, they told him the surgery had been a success and did not tell him about her extravasation injury.
34. The Trust says it apologises if Mrs O’s husband felt he had been misled, but the information the surgeon focused on was the most important aspects of Mrs O’s surgery. This was that the surgery had been successful and Mrs O was in recovery, despite the surgery being technically difficult.
35. We have not been able to find any record of the conversation the surgeon had with Mrs O’s husband in Mrs O’s records. In response to our provisional views report, the Trust told us it did not feel Mr O needed to be told about the extravasation injury, as there was no evidence that it was significant and Mr O would be far more intent on knowing about the difficult major surgery, which carries a mortality risk and which had gone well. The Trust says it makes assumptions about what it feels people most need to understand rather than simply bombarding them with information.
36. We spoke to Mr O directly about the conversation he had with the surgeon. Mr O says the surgeon told him everything had gone well with Mrs O’s surgery and there had been no complications. Mr O says when he saw Mrs O the next day, he could see Mrs O’s arm had sustained injuries and he was shocked by the condition of her arm.
37. Based on the evidence we have considered, we have found the surgeon who spoke to Mr O did not tell him about the extravasation injuries Mrs O had suffered during her surgery.
38. The GMC ‘Guidance on communication, partnership and teamwork’ says doctors must give patients the information they want or need to know in a way they can understand. It also outlines they must be considerate to those close to the patient and sensitive and responsive in giving them information and support.
39. We have found the Trust did not follow the guidance and we have found this to be a failing. We consider it would have been appropriate for the Trust to tell Mr O about the extravasation injury. We discuss the impact of this below.
Impact
Mrs O’s scarring
40. Mrs O says her arm has been left permanently scarred.
41. To determine whether we can link the impact Mrs O is claiming to the failings we have identified, we received clinical advice from a surgical adviser. The surgical adviser says if the extravasation had been identified sooner this would have limited the amount of fluid and medication that was extravasated. As we have outlined in this report, it would have been clinically appropriate to inspect the infusion site 40 minutes earlier than the Trust did so.
42. The photographs Mrs O provided to us clearly show Mrs O suffered injuries to her arm and this caused blistering. Mrs O was reviewed by a plastic surgeon in March 2021.
43. The plastic surgeon said the photographs of Mrs O’s arm taken after her surgery, when she was still an inpatient, show superficial skin blisters that are fairly extensive to the entire area around the middle of Mrs O’s arm and going down into her forearm. The plastic surgeon asked whether the cause of this could be an allergic reaction as opposed to the extravasation. The plastic surgeon said it was not possible to give an absolute diagnosis, but they noted Mrs O’s scars had virtually disappeared, apart from some discolouration, and there were no complications.
44. Clinical advice from our anaesthetic adviser says mild reactions to dressings are very common, but allergic reactions to dressings that lead to scarring are very rare. Mrs O had no history of reacting to dressings in the past and the dressings placed on her left arm during surgery did not provoke a reaction. Our adviser says it is far more likely that Mrs O’s scarring resulted from extravasation. Based on the clinical advice we have received, we think Mrs O’s scarring was likely caused by the extravasation.
45. We have carefully reviewed the three sets of photographs Mrs O has provided to us. One set was taken at the time of Mrs O’s injury. Mrs O says the second set of photos was taken over a year later and the third set of photos was taken in November 2022. We can see there is still some evidence of scarring on the second set of photos. However, there is no evidence to show when these photographs were taken. Our surgical adviser says they were not able to comment on the third set of photos due to the picture quality.
46. Our surgical adviser says they would not expect the fluid and drugs that were extravasated into Mrs O’s arm to cause any permanent scarring. The plastic surgeon’s letter following the review in March 2021 also shows Mrs O’s scars were healing and had almost disappeared by the time she was reviewed. This was around eight months after her injury. The plastic surgeon also added they were confident Mrs O’s scars would improve further with time.
47. After careful consideration of all the evidence we have, we have found the extravasation led to blistering to Mrs O’s arm, which has resulted in scarring to her arm. However, based on the evidence we are unable to say this has resulted in permanent scarring to Mrs O’s arm. We have identified the Trust’s failure to inspect the infusion site when it should have led to a loss of opportunity to mitigate the extent of the injuries to Mrs O’s arm, which resulted in fluid and drugs extravasating into Mrs O’s arm for around 40 minutes, causing Mrs O to suffer extravasation injuries.
48. We are unable to link the Trust’s failure to refer Mrs O to a plastic surgeon to the injuries Mrs O has suffered. Our surgical adviser says the evidence showed no need to do anything other than keep the affected area covered.
49. We understand the injuries to Mrs O’s arm made an already stressful time a lot more difficult. We are very sorry to learn of the injuries caused to Mrs O’s arm, and we accept the impact of the injuries has caused her a lot of upset.
The psychological impact on Mrs O
50. Mrs O says the scarring has made her feel anxious and depressed, as she is very conscious of her scar. Mrs O says it has affected her quality of life, as she feels self-conscious about showing her scar in public. Mrs O also says she suffered upset and concern when she found out the Trust had not told her husband about the cannula leaking into her surrounding tissue.
51. We have found the injuries Mrs O suffered would have caused her a degree of distress. It is clear Mrs O was worried about the condition of her arm, as she asked to be referred to a plastic surgeon to have her arm reviewed. We understand the scarring would have led to Mrs O feeling self-conscious and upset, and we do not underestimate the impact this would have had on her. However, we have seen no evidence this led to depression or that Mrs O has been diagnosed with depression or anxiety because of the scarring caused to her arm. We Have also seen no evidence the injuries had affected Mrs O’s quality of life. The plastic surgeon’s letter stated Mrs O’s scars had virtually disappeared and, apart from some slight discolouration, there were no complications and the injury had not affected Mrs O’s arm movement at all.
52. The plastic surgeon noted as it was only eight months since Mrs O’s injuries they were confident her scars would heal further. We understand the scarring would have caused Mrs O to feel self-conscious and anxious about her arm for several months, particularly up to the point she was reviewed by the plastic surgeon, but we have not seen evidence the scarring has affected Mrs O’s quality of life.
53. We have found Mrs O would have also suffered a degree of frustration and concern when she learnt the Trust had not told her husband about her extravasation injuries when the surgeon spoke to him about her surgery. It is understandable Mrs O would have expected the surgeon to tell her husband about her injuries. Therefore, we have found this would have caused added frustration and upset to Mrs O at what was already a stressful and traumatic time for her.