The family of a man who died at Central Middlesex Hospital, following internal bleeding caused by a failed cannula insertion, has received an apology and compensation from London North West Healthcare NHS Trust following an inquest.
Mr K was admitted to hospital for investigation into a suspected hip fracture after suffering a fall at home. A minor fracture was identified and Mr K was kept for treatment and observation over the course of the next week.
Shortly before his planned discharge, it was decided that one of Mr K’s intravenous lines should be replaced to minimise the risk of line infection. The cannula was taken out of Mr K’s jugular vein and two junior doctors attempted to insert it into a new site, Mr K’s left femoral vein. Unfortunately, after three attempts, the left femoral vein had not been successfully cannulated and bruising had been noticed, so the junior doctors abandoned the attempt.
Mr K initially appeared to be stable, but his haemoglobin began to fall, as did his blood pressure, despite a number of transfusions. Mr K also began to complain of abdominal pain. Unfortunately, no investigations were carried out to determine the cause of these symptoms.
After a number of days, Mr K’s condition began to deteriorate rapidly. A CT scan was taken and was initially reported by a junior radiologist as showing old bleeds, but no active bleeding. In the absence of any active bleeding, no immediate intervention was thought to be necessary. A more senior radiologist reviewed the scan overnight and realised that there was active bleeding, as well as signs of bowel ischaemia – a life-threatening medical condition where there is insufficient blood supply to the intestine.
Sadly, by the time this had been realised, Mr K’s condition had deteriorated to a critical point and it was too late for any medical intervention to be effective.
At an inquest into Mr K’s death, hospital staff admitted that Mr K’s falling blood values and abdominal pain should have prompted urgent investigation which would have diagnosed the bleeding before it reached a critical point. The Coroner provided a narrative verdict which highlighted a number of occasions where opportunities to diagnose the bleeding were missed.
Although the Trust did not formally admit liability for Mr K’s death, negotiations with the family were entered into shortly after the inquest and the case was settled for a 5-figure sum and a formal apology from the hospital.
“Mr K’s death was brought about by a series of missed opportunities that should never have happened in a modern Intensive Care Unit. He was a loving husband and father who will be sorely missed by all those who knew him. Although there is nothing that can be done to bring him back, we hope that lessons will have been learned by the Trust to ensure that other families do not have to suffer a similar experience”.