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Case ref:201203628
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Date:January 2014
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Body:Tayside NHS Board
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C was undergoing treatment for leukaemia and had to have a 'Hickman Line' (a small tube to give long-term access to a vein to administer chemotherapy) inserted. Mr C complained that this procedure was not performed correctly as it had caused him a great deal of pain. He also complained that his complaint about it was not dealt with reasonably.
Our investigation, which included taking independent advice from one of our medical advisers, found no evidence that the procedure was not carried out properly. The adviser said that different patients experience differing levels of pain in such a procedure and there was no evidence that anything went wrong with the first insertion. However, no record of the problems Mr C experienced was made at the time. The radiologist who performed the procedure had, after speaking to Mr C after the procedure, agreed to make a record in the clinical notes and to put an alert on the electronic records saying that Mr C required sedation for any future insertion. This did not happen and, when Mr C had to be admitted for a further line to be inserted, he was distressed that the team were not aware of his experience. Because of this, although we did not uphold the complaint about the procedure, we made recommendations about record-keeping.
On the matter of the complaints handling, it was clear from our investigation that for a number of reasons, there were extended delays in the handling of Mr C's complaint. Some of these were outside the board's control but some were not, and so we upheld this complaint.
Recommendations
We recommended that the board:
- apologise to Mr C;
- conduct an audit of record-keeping in the department and use any learning points to formulate an action plan for improvement;
- ensure their patient information leaflet is provided to patients before consent is given and that this is documented; and
- provide evidence that the complaints handling team have learned from these events and that those learning points have been used to improve the service.