10. When we consider whether there is an indication of a failing in the care and treatment complained about, we first determine what should have happened in line with relevant policies, guidelines, standards and good clinical practice. We then use all available evidence to determine if we can say what should have happened, did happen. If it did not, we then consider if what did happen fell so far short of what should have happened that it amounts to an indication of a failing.
11. If we identify an indication of a failing in the care and treatment provided, we then consider the impact of this failing. If the potential failing has had a negative impact on the complainant and/or the aggrieved, we consider what actions the organisation has already taken to put things right.
Extravasation
12. Mrs A complains the Trust ignored her concerns the IV cannula was not properly in place during her CT scan, causing the contrast dye to leak into her left hand. This is known as extravasation.
13. The Trust said after it inserted the cannula into Mrs A’s hand, it checked it was patent (open and unobstructed, allowing fluid to flow freely through it) by flushing it with saline. The Trust then completed the CT scan, all the while monitoring the administration of the dye on an injector-graph. This is a visual representation of the various measurements involved in administering a contrast dye, including volume and pressure etc. When the Trust completed the CT scan, it noticed from the back of Mrs A’s hand that extravasation has occurred.
14. The Trust said Mrs A moved around and waved her arm between it checking the cannula was patent and it administering the dye, and during the scan, so with retrospect the cannula may have become dislodged then. The Trust said the injector-graph did not suggest there was any high pressure during the scan, which may have suggested the cannula was not properly in place, and so could have leaked. This meant the Trust did not consider it needed to re-check the cannula.
15. The Trust told us the radiology department, where Mrs A had her CT scan, does not keep medical records. We are therefore relying on the testimony of the staff as given in the Trust’s response in place of these.
16. Mrs A says she made staff aware the cannula was not properly in place, but they assured her it was. Mrs A’s daughter, who was there at the time, supports this testimony. We do not dispute Mrs A’s, or her daughter’s, recollection of events. The Trust’s response does not specifically address this allegation, and it does not mention this interaction happened.
17. As we were not there, we cannot say exactly what happened in the room that day, in terms of this interaction or otherwise. We also cannot use the fact that the extravasation happened alone to say the Trust should have done more to ensure the cannula was properly in place.
18. We have seen the photographs of Mrs A’s hand, and so certainly do not underestimate how painful this would have been for her. As we do not have any further corroborating evidence, we would be unable to form a view on what happened. This means, if we did go on to a detailed investigation of Mrs A’s complaint, we would be unable to reach a robust decision on this aspect due to a lack of evidence. We will therefore not consider this aspect of the complaint any further.
Aftercare
19. Mrs A complains the Trust did not provide her with appropriate information about her injury following the incident.
20. The Trust said once it noticed the dye had leaked, it apologised to Mrs A and applied an ice pack to the back of her hand. The Trust said Mrs A’s hand appeared swollen, but not discoloured or blistered. The Trust acknowledges it did not provide Mrs A and her family with written aftercare information as it should have. The Trust explain it has since taken steps to ensure a patient information leaflet regarding extravasation is readily available for staff to give to patients.
21. The Trust have acknowledged it did not do what it should have done here, which is an indication of a failing in Mrs A’s care. We now need to determine the impact of this mistake.
22. The Trust told us it has now formalised a patient information leaflet regarding extravasation, implying one was not available before. Manchester Trust’s information leaflet recommends elevating the affected limb, and applying ice packs, if extravasation occurs. It also mentions seeking advice from a GP or attending A&E if blistering occurs.
23. Mrs A’s records detail her attending the urgent treatment centre (UTC) at the Trust the next day as her skin had blistered overnight. This was the correct course of action, and thankfully Mrs A took this despite not receiving any aftercare information. The Trust then provided Mrs A with advice and treatment regarding the extravasation. We therefore need to focus our consideration on the time between the injury and Mrs A attending the UTC.
24. If the Trust had provided Mrs A with the correct aftercare information, she would have known to elevate her hand and apply ice packs. We recognise the Trust not doing so meant Mrs A was not aware of this information, and so may not have taken these steps. It would not be possible for us to say with any certainty that Mrs A’s hand would not have blistered, or her long-term outcome would have been any better, had she taken these steps in this time.
25. We recognise that if Mrs A had elevated her hand and applied an ice pack, this likely would have provided her with some relief from her pain. This means we can say the Trust’s mistake likely meant Mrs A suffered from an unnecessarily increased level of pain between the evening of 26 January and the afternoon of 27 January.
26. Mrs A is looking for financial compensation as an outcome to her complaint. Our severity of injustice scale says complaints where we can determine the physiological impact is, ‘Short term minor pain (no more than 1-2 days), which can be managed by use of non-prescription medication and where the person affected can still function normally’, fall at level 1. We do not consider that these complaints warrant a financial outcome.
27. We have determined the Trust’s mistake meant Mrs A lost an opportunity to somewhat relieve her level of pain for a period of less than 24 hours. We recognise Mrs A was not able to use her hand, but we cannot say she would have been able to if she had been elevating it and applying an ice pack. We therefore consider her complaint falls at level 1 on our scale.
28. Our Standards say if an organisation finds failings which have had an impact of any kind, the first step is to provide a meaningful apology. They also say to put things right, organisations may consider revising policies and procedures to stop the same thing happening again, and training or supervising staff.
29. We understand how frustrating it must have been for Mrs A to feel like she had missed an opportunity to treat her injury appropriately. The Trust have apologised for its mistake, and taken steps to reduce the risk of a recurrence with another patient. As we have determined a financial outcome is not appropriate, we would not expect the Trust to do any more than it has done to address this concern. We will therefore not consider this aspect of the complaint any further.