Decision Report 201607658

Summary

Mr C was being treated at the Beatson Cancer Centre when his cannula became dislodged causing chemotherapy to leak into the surrounding tissue and skin. He was taken to Glasgow Royal Infirmary and a procedure was carried out to remove the chemotherapy. Mr C complained that the nursing staff had not properly inserted the cannula or monitored his treatment. Mr C also complained that staff did not appear to know what to do following the incident, and he raised concerns about the length of time it took to be referred to plastic surgery.

We took independent advice from a nursing adviser. We found that whilst Mr C was aware that he had to report any problems with his cannula to staff, the nursing staff had not documented having given this advice. The board had acknowledged this failure in record-keeping when responding to the complaint and advised of the action they had taken to address the matter. We identified further evidence of poor record-keeping which was not in line with Nursing and Midwifery Council guidance in terms of the accuracy of information documented and that several nursing care entries were not timed.

We did not find clear evidence to show that the nursing staff had failed to properly insert or monitor the cannula. In addition, we identified that there was evidence to demonstrate that the appropriate action was taken following the incident to address the leakage. We also found that there was no undue delay in Mr C being transferred to Glasgow Royal Infirmary. We did not uphold the complaint.

Recommendations

What we said should change to put things right in future:

• Staff should ensure full and accurate records are documented in line with Nursing and Midwifery Council guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.