Nottinghamshire Healthcare NHS Foundation Trust

4. Mr R complains the Trust incorrectly followed the PICC wound cleaning procedure on 13 January 2022.

5. Mr R says this led to getting an infection in his right bicep and DVT, and needing to be in hospital for eight days. He says he had to have surgery to insert a new PICC line in his left armpit, which caused him distress. He also says he experienced ongoing anxiety and worries about future wound cleaning procedures.

6. Mr R wants to know the Trust will improve. He wants an apology and a financial payment.

7. Mr R needed a PICC line in his right armpit for his chemotherapy medication. A district nurse needed to clean the wound on a regularly using a dressing pack.

8. Mr R says when the nurse cleaned his wound the PICC line came out of place. He says the nurse did not wear the sterile gloves from the dressing pack. Mr R says he started to feel unwell the next day.

9. On 17 January, Mr R went to the emergency department (ED) because his symptoms got worse. He was diagnosed with an infection and DVT in his right bicep. He was in hospital for eight days.

13. Mr R remembers the nurse reinserting the PICC line when it came out of place.

14. The Royal Marsden guidance says if there is movement with a PICC line, it should not be reinserted. Instead, all medication should be stopped and the ED should be contacted.

15. Our surgeon adviser explained that if a PICC line comes out of place, it could be exposed to skin flora (microorganisms that live on the top layer of the skin), and reinsertion could mean flora enter the arm through the wound. The records show the organisms that caused Mr R’s infection were staph aureus, which is a common skin organism.

16. If the PICC line had not come out of place and been reinserted, it likely would not have become exposed to skin flora, and Mr R would not have got the infection and DVT.

17. We have found a failing in the Trust’s handling of Mr R’s PICC line. Mr R was hospitalised for eight days due to the infection and DVT he got from the poor care. The complications he faced and the eight-day hospital admission caused him distress and anxiety when he had his wound cleaned again. The Trust did not find any failings when it investigated the complaint.

18. Our Principles say when something has gone wrong and this has an impact, the organisation should take action to put things right. The Trust has not accepted that anything went wrong and has not taken any action.

19. We uphold this complaint and make recommendations below.

1. Mr R is understandably concerned that Nottingham Healthcare NHS Foundation Trust (the Trust) incorrectly followed the peripherally inserted central catheter (PICC is a thin tube inserted into a vein to give medication or liquid nutrition) wound cleaning procedure. We can see why this caused him anxiety because he went on to develop an infection and deep vein thrombosis (DVT) in his right arm. We are sorry to hear about what he has been through.

2. We found the Trust’s wound cleaning procedure was not in line with relevant guidelines. We found the Trust’s wound cleaning procedure meant Mr R got an infection which had a big impact on him because he had leukaemia. We uphold this complaint.

3. The Trust has not accepted these failings. We recommend it apologises to Mr R and pays him £750. We also recommend the Trust writes an action plan to show how it will learn and improve its service.

20. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These say that where something has gone wrong that has affected someone, the organisation responsible should take steps to put things right.

21. Our Principles say that organisations should look for continuous improvement and should use the lessons learned from complaints to make sure they do not repeat maladministration (fault) or poor service.

22. We recommend the Trust: • write to Mr R to acknowledge the failings we have found in PICC line wound care and apologise for the impact this had on him • create an action plan to address the failings we have found in PICC line wound care. The action plan should include the action, who is responsible for it, the timescale for completing the action and how it will be monitored to make sure of improvement.

23. Our Principles say that organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not happened. If that is not possible, it should compensate them appropriately.

24. To decide on a level of financial payment, we review cases where the person has experienced a similar injustice (impact) and we use a tool for deciding how serious the impact was. We have decided the Trust should pay Mr R £750 to recognise how he has been affected.