18. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
Cannulation
19. Ms H says the consultant gastroenterologist refused her request to fit a PICC line (peripherally inserted central catheter) for her intravenous (IV) medication, and instead staff had to cannulate several times during her stay in hospital.
20. Ms H said she had a PICC line arranged by the Trust the previous year in anticipation of three procedures and she had expected staff would facilitate this during this admission.
21. A mid-line catheter is a long, thin tube inserted into a vein in the upper arm for administering medications or fluids intravenously for a longer period than a standard cannula. A PICC line is used for a similar purpose but is longer and is threaded into a central vein in the chest, near the heart.
22. The Trust said it is regrettable that it took several attempts to cannulate Ms H. It said this is unusual and could not have been predicted.
23. It said there are risks associated with mid or PICC line insertion (including local infection, septicaemia and blood clots), and if possible, the Trust aims to avoid insertion of such lines in patients who do not need regular long-term intravenous treatment.
24. Although there are NICE guidelines on standards of care once a mid or PICC line is in place, these guidelines do not specifically state when it is necessary to use these instead of more usual means of access to peripheral veins.
25. The Trust has a policy for venous access devices which includes PICC lines. This policy emphasises the risks and complications involved in having a PICC line, which include infection, blood clots and bleeding and bruising. The policy also explains a midline is typically used for up to eight weeks and can be used in instances of poor venous access, whereas a PICC line is for up to two years. Ms H’s admission on this occasion was one week.
26. The records show Ms H made staff aware early on in her admission that there had been some difficulty cannulating her in previous hospital stays. A doctor spoke with her about this and discussed the possibility of using a PICC line, and said he would raise this with the consultant.
27. The next day, the consultant spoke with Ms H and explained the Trust has a duty not to do harm to a patient. The consultant reiterated that repeated IV lines can create a risk of clots and can cause damage to the veins, so the Trust had to be minimalistic in its approach.
28. We acknowledge Ms H said the Trust attempted to cannulate her on 66 occasions and therefore feels the number of unsuccessful attempts was enough to justify the use of a PICC line. Ms H has provided some photographic evidence which shows bruising to various parts of her skin, which she says is evidence of these attempts.
29. We have seen no reason to doubt Ms H’s account, however we have seen no documented evidence to show there were 66 unsuccessful cannulation attempts. The records show only four documented replacements of Ms H’s cannula during her admission. We have also not seen sufficient evidence to say Ms H missed medication in this time. Ms H’s medication record shows the infusions the Trust had prescribed were all administered when required.
30. Our gastroenterology adviser said from the evidence available, there was no prolonged period without venous access, and the decision from the Trust not to use a PICC line was correct as it would be difficult to justify the risk of PICC line insertion.
31. Ms H also said she missed important IV anti-epileptic medication due to not having a cannula in place, and this caused her to suffer two seizures.
32. The Trust said Ms H’s seizures appeared to be non-epileptic or functional (dissociative), which are not caused by abnormal electrical activity in the brain. The Trust said as the seizures were thought to be non-epileptic, missing a dose or two of medication is unlikely to be relevant.
33. The NHS says a functional seizure (also called a dissociative seizure) is an episode where someone loses either their awareness of, or their ability to interact with, their surroundings. A functional seizure can appear as:
• uncontrolled shaking • suddenly going motionless and unresponsive • staring without responding to surroundings.
34. Our adviser said based on the description of Ms H’s seizures from the records, these appeared to be functional in origin and not epileptic episodes. We have not seen any evidence that shows Ms H missed her anti-epileptic medication, however, we also do not consider her seizures to be related to missing epileptic medication, based on the evidence we have seen.
35. We understand Ms H has had difficulties with cannulation in the past and so she asked to have a PICC line inserted. We consider the Trust balanced the risks associated with PICC line insertion against the benefit it would provide to Ms H, especially considering the short duration of her stay on this occasion. We have not seen any indications the Trust did anything wrong in denying this request.
Psychiatry referral
36. Ms H said the consultant referred her for a psychiatric assessment for drug seeking and functional behavioural problems. Ms H said she felt insulted by this and feels there is now a black mark on her medical records. Ms H said she is worried she will be treated differently in future hospital admissions because of this.
37. The Trust said the referral was due to Ms H’s frequent requests for cyclizine outside of the prescribed regime (as intravenous cyclizine is known to have addictive properties). It said the psychiatric team did not find any diagnosable disorders and reflected this in Ms H’s discharge summary.
38. Cyclizine is a common anti-sickness medication that can be administered intravenously to prevent severe nausea and vomiting. Ms H had been taking cyclizine intravenously due to her difficulties swallowing. Guidelines for its use from the British National Formulary say for an adult the appropriate intravenous dosage is 50mg up to three times a day. This is what the Trust had prescribed.
39. Information from the General Pharmaceutical Council says cyclizine is known to be addictive and there are reports of cyclizine dependence and medication seeking behaviours, particularly when taken intravenously.
‘There are known reports of cyclizine misuse due to its sedative and euphoric nature. Cyclizine is a central nervous system (CNS) depressant and so the effects of this are enhanced when it is taken alongside other medicines and substances that are also CNS depressants. Examples include alcohol, benzodiazepines and opioids’
40. The records show several occasions of Ms H asking for additional doses of cyclizine outside of her prescribed regime. As cyclizine is not to be prescribed on an as required basis, staff were unable to accommodate Ms H’s requests.
41. Our adviser said it was a reasonable clinical question for the consultant to be concerned about the frequency of these requests, given the addictive nature of IV cyclizine. The adviser said Ms H has a difficult combination of physical illness and functional disorders which do not have an underlying physical basis, and the referral to liaison psychiatry was to explore if there were any underlying psychological issues driving this behaviour which may have had alternative treatment options.
42. The adviser added there is evidence to show Ms H had also asked to have intravenous oxycodone (a strong opiate) to replace her oral medications, which would also suggest there may have been an element of addiction present.
43. We understand Ms H may have been surprised to be referred to liaison psychiatry and felt the consultant had not communicated with her fully to explain the reason for this referral. We consider this referral was in her best interests and we have seen no indications the Trust did anything wrong.
Gastroparesis diagnosis
44. Ms H said the consultant gastroenterologist who treated her dismissed a long-standing diagnosis of gastroparesis. Ms H said she was diagnosed with gastroparesis in 2017 following an endoscopy.
45. Ms H disagreed with information in the discharge summary she received from the Trust following her admission, in which the consultant stated ‘possible gastroparesis’. Ms H said she was left concerned about this affecting any future treatment, and whether to inform staff in an upcoming pre-op whether she had issues with food remaining in her stomach.
46. Ms H contacted the consultant to query this, and the consultant explained he did not think gastroparesis had been proven and was possibly unlikely.
47. The Trust said that due to inconclusive investigation findings since Ms H’s first endoscopy in February 2016, the diagnosis of primary gastroparesis remained unproven, although not disproved.
48. Gastroparesis is a long-term disorder characterised by symptoms suggesting retention of food in the stomach. Symptoms include feeling full sooner than usual, bloating and feeling sick.
49. There are no specific national guidelines on diagnosing gastroparesis, although there are US clinical guidelines on the diagnosis and our adviser said best practice in England would be in line with these.
50. The guidelines state that it is customary when diagnosing gastroparesis to use gastric emptying studies and neurophysiology (the physiology of the nervous system). The guidance also adds it is not possible to make a firm diagnosis of gastroparesis in someone regularly taking opiates.
51. Our adviser said opiates delay gastric emptying, and Ms H regularly takes oxycodone, a strong opiate. The adviser also said Ms H’s previous duodenal (the first part of the small intestine) surgery from 2017 may affect her gastric emptying.
52. Based on the evidence we have seen, we consider it was reasonable for the consultant to comment on the possible doubt around the gastroparesis diagnosis given the combination of factors that may be affecting this.
53. We understand it may have been a shock for Ms H to discover this in the discharge summary, but we have not seen any indications the Trust has done anything wrong.
Conclusion
54. We acknowledge Ms H had concerns about the way the Trust treated her during her admission. We hope our investigation will provide reassurance the Trust’s actions were in line with relevant standards and guidelines.