Hospital admission
10. Mr O complains between 1 and 5 March he was unnecessarily kept in hospital for further investigations. He says he only required a blood transfusion and did not want to remain in hospital because he is his partners carer and no one was at home to look after her.
11. The Trust set out what is in Mr O’s records and said the best way to monitor Mr O was in hospital. It found no failings in its decision to admit Mr O.
12. We will now review the records.
13. Mr O arrived at the Trust’s ED (Emergency department) at 2.25pm following advice from his GP. It is recorded he presented with symptomatic anaemia.
14. At 3.20pm it is noted Mr O complained of shortness of breath and general weakness and abdominal pain. It is recorded Mr O explained the abdominal pain radiated to his back. The Trust recorded Mr O’s NEWs score as 2 at 3.39pm,
15. National Early Warning Score (NEWS) is a standardised system used to assess the risk of patient deterioration in hospitals and other healthcare settings. A score of zero to three is considered low risk.
16. Within the ED, at 5.07pm, the Trust carried out an electrocardiogram. The Trust also requested the following tests, venous blood gas, glucose, lactate, urea and electrolytes, liver function tests, C-reactive protein and full blood count
17. At 7.16pm Mr O was admitted to the Trust. It is noted Mr O symptoms were noted as shortness of breach, lethargy, malaise, weakness, reduced appetite, muscle aches, headaches and dizziness. It is recorded his reason for admission was symptomatic anaemia. Mr O’s NEWs score was one. He had a hemoglobin level (Hb) score of 56 g/litre which is a sign of severe symptomatic anaemia.
18. Hemoglobin count refers to the amount of hemoglobin, the protein in red blood cells that carries oxygen, in a person's blood. The management plan was noted as a blood transfusion and to recheck after.
19. NICE guideline, Blood transfusion says:
‘1.2.1 Use restrictive red blood cell transfusion thresholds for patients who need red blood cell transfusions and who do not: • have major haemorrhage or • have acute coronary syndrome or • need regular blood transfusions for chronic anaemia.
1.2.2 When using a restrictive red blood cell transfusion threshold, consider a threshold of 70 g/litre and a haemoglobin concentration target of 70–90 g/litre after transfusion.
1.2.3 Consider a red blood cell transfusion threshold of 80 g/litre and a haemoglobin concentration target of 80–100 g/litre after transfusion for patients with acute coronary syndrome.’
20. As set out above, Mr O’s Hb levels were lower than the recommended thresholds. We consider the Trust decision to provide a blood transfusion is supported by NICE guideline, blood transfusion.
21. NICE guideline, Blood transfusion, goes on to say:
‘1.2.6 After each single-unit red blood cell transfusion (or equivalent volumes calculated Blood based on body weight for children or adults with low body weight), clinically reassess and check haemoglobin levels, and give further transfusions if needed.’
22. The guidance does not specifically say when a patient should be admitted. It does say there is a need to clinically reassess and check Hb levels. It says further transfusions should be given if needed.
23. Our physician adviser explains Mr O’s treatment would be considered urgent in view of the symptoms he was experiencing, and the severity of the anaemia (56 g/litre), therefore, necessitating a hospital admission. It would be expected that he would require multiple blood transfusions to reach the target Hb level recommended by treating clinicians. Mr O would require hospital admission to deliver the transfusion(s).
24. Given the requirement of a number of blood transfusions and the nature of his symptoms we consider the Trust’s decision to admit Mr O was appropriate.
25. We have continued to review Mr O’s admission.
26. There is no specific guidance on how long an admission should be or when a patient should be discharged.
27. GMC Good medical practice says:
‘7 In providing clinical care you must: • adequately assess a patient’s condition(s), taking account of their history, including symptoms • relevant psychological, spiritual, social, economic, and cultural factors the patient’s views, needs, and values • carry out a physical examination where necessary • promptly provide (or arrange) suitable advice, investigation or treatment where necessary’
28. The Trust’s Blood and Blood Components Transfusion Policy says:
‘1.7 Transfusion based on haemoglobin concentration (adults) • Acute anaemia, cardiovascular disease, the Hb threshold is 80g/litre and a Gb target of 80-100g/litre’
29. We will consider the actions of the Trust in line with this guidance.
30. At 10.45pm the Trust started the first blood transfusion. It is recorded this ended on 2 March at 2.45am. Mr O’s Hb score was 62 g/litre
31. On 2 March at 9.08am Mr O was seen by the consultant. It is recorded Mr O was mobilising well and was alert. The investigations and management plan notes Mr O’s blood pressure was to be reviewed at 6pm and there was also to be a gastrointestinal review.
32. GMC Good medical practice explains in providing clinical care the Trust should promptly arrange suitable investigations. The Trust’s decision to provide a gastrointestinal review is in line with this. Our physician adviser agrees a gastroscopy was appropriately planned to further investigate any ongoing blood loss.
33. A second blood transfusion started at 10.30am and finished at 2.15pm. Mr O’s Hb score was 76 g/litre. There are no further notes regarding the care on 2 March.
34. On 3 March at 1.30am it was noted Mr O did not complain of any pain. A NEWs score of one is recorded.
35. At 10.06am Mr O was reviewed. It is noted he complained of no pain, was stable and mobile. His NEWs score is recorded as zero.
36. A third blood transfusion started at 4.40pm. The record does not say what time this ended. After the transfusion Mr O’s Hb score is noted as 84 g/litre.
37. We consider at this point Mr O had reached the threshold Hb score as set out in the Trust’s policy. We have not seen at this point his gastrointestinal review had taken place.
38. On 4 March Mr O was reviewed at 4.20am. His NEWs score is recorded as one.
39. At 9.02am Mr O was reviewed. Under plan it is noted he was to undergo another blood transfusion. It is also recorded the Trust would like to perform an OGD (oesophago-gastro-duodenoscopy). This is a medical procedure used to examine the upper digestive tract. The notes indicate the Trust’s aim is to discharge Mr O the following day (5 March) after the OGD.
40. At 4.32 pm Mr O was reviewed. It is recorded he had a NEWs score of three.
41. At 6.40pm Mr O’s forth blood transfusion was due to start. The notes explain when attempting to put the cannula in, the canula ‘tissued’.
42. Cannula ‘tissued’ refers to the leakage of fluid from a vein into the surrounding tissue, a condition known as extravasation. This occurs when a cannula, the flexible tube used for intravenous (IV) infusions, punctures the vein, and the medication or fluid then enters the tissue instead of the bloodstream.
43. The Trust stopped the infusion and removed the cannula.
44. At 11pm Mr O was reviewed. No further action had taken place since 6.40pm. It is noted the Trust were to hold off the fourth blood transfusion. Under the plan, the Trust’s day team would review the need for any further blood transfusions. It is also noted the Trust had now managed to cannulate Mr O.
45. At 11.45pm Mr O explained to the Trust he was not happy with the care which had been provided. Mr O explained he would like to discharge himself. On 5 March at 12.37am Mr O left the Trust.
46. We acknowledge Mr O was frustrated with his admission as he felt only a blood transfusion was necessary. We have seen his Hb scores were very low and required treatment in line with NICE guideline, blood transfusion. We consider it was appropriate to admit Mr O so his Hb scores could be monitored and a number of blood transfusions could be given. The Trust acted in line with GMC guidance and ordered appropriate investigations.
47. We can see an OGD was due to take place on 5 March. The Trust indicated this would have been the day Mr O was discharged. We are persuaded by the evidence there are no indications of failings here. We consider Mr O’s admission, and the Trust investigations were appropriate.
Iron Transfusion
48. Mr O complains the Trust incorrectly positioned the iron transfusion in his arm. He explains this caused a leak which turned his arm orange. Mr O says the Trust failed to follow procedure following this. Mr O says this caused pain and his arm to swell. Mr O says his arm remains painful to this day.
49. The Trust acknowledged Mr O’s cannula had leaked into his arm. The Trust said the nursing team acted quickly to stop the infusion and remove the cannula. It apologised for its communication with Mr O.
50. We have reviewed the records.
51. On 4 March At 6.40 Mr O’s forth blood transfusion was due to start. The notes explain when attempting to put the cannula in, the canula ‘tissued’. The Trust stopped the infusion and removed the cannula.
52. Tissuing is a commonly used term to describe ‘extravasation’. Extravasation is the accidental leakage of any liquid intended for venous administration into the surrounding tissues instead. Our nursing adviser explains extravasation is not a failing in its own right as it can be caused by a several factors including small or fragile veins, difficult cannulation or accident displacement. This list is not exhaustive.
53. We will now consider what steps the Trust took following extravasation.
54. There is no national guidance specific to extravasation. NICE treatment summaries, soft tissue disorders, says:
‘If extravasation is suspected the infusion should be stopped immediately but the cannula should not be removed until after an attempt has been made to aspirate the area (through the cannula) in order to remove as much of the drug as possible. Aspiration is sometimes possible if the extravasation presents with a raised bleb or blister at the injection site and is surrounded by hardened tissue, but it is often unsuccessful if the tissue is soft or soggy.’
55. The treatment summary goes on to say:
56. ‘The management of extravasation beyond these measures is not well standardised and calls for specialist advice.’
57. In line with NICE treatment summaries, soft tissue disorders, the Trust stopped the infusion. The records show the Trust also removed the cannula. The notes do not say if an attempt to aspirate the area was made. As we cannot say how the site of the injection was at the time, we will not be able to say it an attempt to aspirate should have been made.
58. In the absence of standardised guidance on extravasation, we have considered what actions the Trust should have taken.
59. British Society for Haematology Guidelines say:
‘Before organising the collection of a blood component, the following should be ensured by the clinical staff: • There is suitable and patent intravenous (IV) access
60. The guidance states only when there is a clear IV access should a transfusion take place. After the canula tissued, we consider there was no longer clear access.
61. Our nursing adviser explains a transfusion should only be given through a clear line (vein). If there are doubts over the line the cannula should be removed.
62. We acknowledge the experience of tissuing has been upsetting for Mr O. We are sorry to hear how he still experiences pain. The fact his transfusion tissued is not a failing in itself. We are persuaded by the guidance the Trust took suitable action to stop the transfusion. We find no indications of a failing.
Vein
63. Mr O complains the Trust took five hours to find a vein for his blood transfusion. He says the process of trying to find his vein caused a great deal of pain.
64. The Trust set out what was in Mr O’s records. It acknowledged in its complaint response the doctor was unable to attend for some time. It apologised for the delay he experienced.
65. We have reviewed the records.
66. On 4 March At 6.40 during Mr O’s forth blood transfusion when attempting to put the cannula in, the canula ‘tissued’. The Trust stopped the infusion and removed the cannula.
67. At 7.05pm an on call doctor was contacted and explained they would be there in 15 minutes. A new canula was not put in until 11pm.
68. There is no specific guidance for how long it should take to replace a removed cannula.
69. NMC ‘The Code’ says:
‘13.2 make a timely referral to another practitioner when any action, care or treatment is required 13.3 ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence’
70. In line with NMC guidance a timely referral was made to the on call doctor once the cannula was removed. The nurse requested help from a suitably qualified and experienced professional. Our nursing adviser explains the actions taken were appropriate.
71. We understand it is distressing having to wait for treatment. We have seen the nurse requested assistance in line with The Code. It took five hours to replace Mr O’s cannula. It would have been better for the cannula to be replaced sooner, however, there is no guidance on how quickly this should happen. We recognise hospitals are busy places and doctors need to prioritise patients that require urgent care and this can sometime cause delays. We consider the care did not fall so far below what we would expect to be considered an indication of a failing. We are pleased to see the Trust have apologised for this delay which is an appropriate action to take.
Overnight Transfusion
72. Mr O complains the Trust incorrectly informed him he could not have an overnight transfusion. He says this is incorrect as he had received one in December 2023. Mr O explains the lack of help from the Trust meant he had to discharge himself from the Trust.
73. The Trust said blood transfusions are not carried out in the evening unless a patient is at high risk and is symptomatic. Mr O was not symptomatic or high risk at the time of the decision. The transfusion was deferred until the next day.
74. We will now review the records.
75. The notes set out at 11pm on 4 March the Trust explained it is not hospital policy to transfuse a patient overnight unless they are unwell, unstable or actively bleeding.
76. The Trust, Blood and blood components transfusion policy, sets out:
‘6.10.1 Monitoring and Observation of Transfusion Patients The following pre transfusion baseline observations must be measured and recorded immediately before transfusion of each unit of blood component. The time should also be indicated on the observation chart page of the ICP.
• Temperature, Pulse, Blood Pressure, Respiratory Rate and Oxygen Saturations.
Patients must be observed closely for symptoms and signs of a transfusion reaction during the 15 minutes after the commencement of each new unit. The patient should be in an area where they can be easily observed.’
77. The Trust’s policy does not specifically say transfusions should not be carried out overnight. It does say a patient should be closely monitored.
78. Our nursing adviser told us unless it is an emergency, transfusions take place through the day when there are more staff around and the patient is awake and alert and able to recognise and report potential adverse effects.
79. British Society for Haematology Guidelines says:
‘If there is no clear clinical indication to transfuse overnight, consideration should be given to deferral of transfusion to the following day.’
80. From the records we have not seen a clear clinical indication a transfusion was required overnight. The Trust’s decision to wait until the next day is line with administration of blood components.
81. We understand Mr O’s frustration he could not receive a transfusion overnight when during a previous admission he received one. We are unable to comment on his clinical presentation during his previous admission. The information provided to Mr O by the Trust was correct and in line with The Trust, Blood and blood components transfusion policy and British Society for Haematology Guidelines. We have not seen an indication of a failing.