A&E staff failed to notice a cannula was inserted incorrectly

What happened

Mr E went to A&E in winter 2011 with a painful knee and poor mobility. Staff assessed him and discharged him home with pain relief. The next day he returned to A&E because his condition had deteriorated.

Staff put a cannula into Mr E's groin. However, they placed it incorrectly, and did not realise this for some hours. When staff took the cannula out, Mr E bled considerably. His condition deteriorated and he went into the critical care unit, where he died in early 2012. Mr E had had a heart attack and had failing kidneys and a lung infection when he died.

What we found

The Trust's assessment when Mr E first went to A&E was appropriate. However, staff did not consider Mr E's mobility before they discharged him, as they should have. Had staff thought about Mr E's mobility, they would not have sent him home in discomfort to sleep on an inflatable bed in his lounge.

There were failings in how staff placed the cannula and in how they took it out. Wrongly placing a cannula is a known risk, so staff should have seen and acted on this promptly. They did not. It was four hours before anyone noticed the error.

Staff should have checked Mr E carefully once they had discovered the wrongly placed cannula because he was taking medicine that would affect how his blood clotted.

The records of what happened are not clear. There were also delays in completing a serious incident investigation and the Trust handled Mrs B's complaint poorly. At first, it did not acknowledge the fault and it did not fully address the issues Mrs B raised.

Putting it right

The Trust wrote to Mrs B acknowledging and apologising for the failings. It paid her £3,000 to recognise her distress.

It drew up an action plan that set out what it had done or will do to stop the failings happening again.