Patient put at risk of blood–borne diseases by Practice nurse

What happened

In winter 2013, Ms K went to her GP practice for an influenza vaccine. The Practice nurse injected her with a previously used syringe when she gave the vaccine. Ms K was exposed to the risk of blood–borne diseases, and consequently had to undergo tests and have an accelerated course of hepatitis B vaccinations. Ms K received the all clear in summer 2014. The incident caused Ms K significant distress and anxiety because she was worried she might have contracted HIV or hepatitis.

Ms K complained to the Practice, which gave written responses and also met her. However, the matter remained unresolved.

What we found

We partly upheld this complaint. There was a failing on the part of the Practice because the Practice nurse had injected Ms K with a previously used needle. This should not have happened and the Practice nurse should have realised the syringe had already been depressed before she tried to give the vaccine. The Practice accepted that this incident should not have happened but its written response did not specifically acknowledge that the Practice nurse was responsible. The response only said that it had not been possible to identify who had put the used syringe back in the fridge. We considered that the Practice needed to acknowledge and address the Practice nurse's responsibility.

We also considered the Practice's actions after the incident. The Practice took the matter seriously and it reported the matter to the appropriate organisations such as Public Health England. It also improved the security of the vaccine fridges to ensure only clinical staff have access to them, and all staff had extra training to make sure they complied with the relevant protocols and procedures. These actions were appropriate in trying to avoid a similar incident happening again. The Practice also gave Ms K reassurance and carried out appropriate screening for any blood diseases. Overall, we considered the Practice's actions to address the serious error by the Practice nurse were appropriate and reasonable. However, while we welcomed the Practice's actions, we considered it should do more to put things right by offering Ms K compensation for the stress and anxiety she had suffered while she waited to find out whether she had any blood–borne diseases.

Putting it right

The Practice wrote to Ms K to acknowledge and apologise for the Practice nurse's actions and the impact this had on her. It also paid her £500 as compensation for the injustice that she suffered.