Decision Report 201405167

Summary

Mrs C was in the Royal Infirmary of Edinburgh for emergency surgery. After she was discharged, she experienced pain, swelling and numbness in her forearm and hand. She felt this was the result of the insertion of a cannula (a thin tube to administer medication, drain fluid or insert a surgical instrument) in her wrist.

We took independent advice from a nursing adviser and a medical adviser, who is a hospital consultant. We found there was poor record-keeping in relation to the care of Mrs C’s cannulas, and that not all of the cannula care was in line with expected good practice. We upheld Mrs C’s complaint.

Recommendations

We recommended that the board:

• provide us with the most recent audit of cannula care to show that it has improved;
• remind staff of the importance of expected good practice in cannula care, in line with relevant local and national standards and guidance; and
• remind staff of the importance of record-keeping as noted in the relevant guidance.