20. To reach a decision about whether the clinical care and service provided was reasonable, we consider the evidence from all parties to the complaint. In this case, we have considered if we can apply a balance of probability. By this we mean, taking a view that something is more likely than not to have happened from the evidence we have available to us.
21. In this investigation, we reviewed whether the venesection procedure delivered by the Trust met a reasonable standard, taking into accounted expected clinical practice, recognised risks, and the Trust’s response after the complaint was raised.
Nursing care
22. We have carefully considered Mrs T’s concerns about the torniquet being left in place and the nurse pressing down hard on the tip of the needed in line with the guidance for venesection. We have sought advice from our adviser. They explain venesection is generally considered a safe procedure when performed in line with recognised guidance. However, it is associated with known risks and complications, including the development of haematoma.
23. Both the Royal College of Nursing and Haemochromatosis UK provide guidance around the use of the torniquet. These explain that once the desired amount of blood has been taken, the tourniquet or blood pressure cuff should be removed, the needle withdrawn, and firm pressure applied to the puncture site or between two and five minutes, ideally by the healthcare professional. The guidance also states that haemostasis should be checked, and a firm dressing applied.
24. The guidance also makes clear that even when venesection is carried out appropriately in and in line with these steps, haematoma can still occur as a recognised complication.
25. Taken together, this guidance indicates venesection should be carried out in line with recognised procedural steps, but haematoma is a known complication which may still occur despite appropriate care, and that where adverse outcome arises, organisations should take reasonable steps to reflect on the care provided.
26. To reach a decision about whether the clinical care and service provided were appropriate, we considered the evidence from all parties and applied the balance of probabilities. This means we have considered the evidence to see if we can determine what is more likely than not to have happened.
27. We recognise that Mrs T experienced pain, bruising and distress following her venesection, and this has had an ongoing impact on her confidence in undergoing further procedures. We do not doubt the impact this has had on her.
28. We are mindful that the records do not provide detailed information about the pressure applied following the needle removal. Equally, there is no indication within the records that any steps in the venesection process were missed, or the procedure was carried out outside expected practice. In circumstances where the available evidence does not allow us to establish precisely how a complication occurred, we must consider whether there is sufficient evidence to conclude that a service failure is more likely than not to have taken place.
29. Having balanced Mrs T’s account with clinical advice and available records, we are unable to conclude, on the balance of probabilities, the haematoma arose as a result of a failure in the venesection procedure. Our adviser confirms that this outcome can occur even where care is provided appropriately, and we have not seen any evidence that would allow us to reach a different conclusion.
30. We have next considered the Trust’s handling of Mrs T’s concerns, in line with our ‘Complaint standards’. These emphasise the importance of organisations acknowledging the impact of an event on a patient, investigating concerns, and taking proportionate steps to learn and reduce the risk of reoccurrence where possible.
31. The Trust’s complaint response acknowledged and apologised for the distress and pain Mrs T experienced and confirmed the nurse involved would not perform venesection on Mrs T again. We consider these actions were in line with our ‘Complaint standards’.
32. Although the Trust’s consideration did not find evidence of concern in the nurse’s care, we also consider it was appropriate to confirm the same nurse would not perform the procedure again for Mrs T, in light of her worries about undergoing this procedure again. We consider this shows the Trust listened to Mrs T and took her concerns seriously.
33. The Trust also explained that a senior nurse held a reflective discussion with the nurse who performed the venesection. It said following this, there was a period of monitoring during which the senior nurse observed the nurse performing venesection procedures on other patients to provide assurance about her competence.
34. We consider these actions were also in line with the NMC guidance ‘The Code’. These emphasise the important of reflection as part of safe and effective nursing practice. Reflection is described as an essential element of learning and professional development. It supports nurses to identify learning and to improve future practice in the interests of patient safety.
35. Overall, we consider the Trust has appropriately considered Mrs T’s concerns and has taken learning from this. We therefore do not see indications to suggest further action is needed.
Conclusion
36. We understand that this is not the outcome Mrs T was hoping for, and we do not wish to diminish the significance of her experience or the impact it had on her. We hope this statement clearly explains our decision not to consider her complaint further and gives her reassurance that the Trust has taken her complaint seriously.