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A cannula complication

14 September 2014

Mrs H, a 28-year-old massage therapist, was admitted to hospital for laparoscopic tubal ligation. Dr T was the anaesthetist for this surgery.

Before the surgery, Dr T placed a cannula in Mrs H’s right wrist and, after surgery, a patient-controlled analgesia (PCA) was commenced through this cannula. According to the cannula chart, a cannula was also placed in Mrs H’s left hand, although this was not in place following surgery. Mrs H also recalled a cannula site in the left forearm and a further cannula site in the right forearm following surgery, although these were not recorded on the cannula chart.

Records show that a day later, slight bloodstaining was present at the cannula site in Mrs H’s right wrist. The following day, Mrs H reported the site of the cannula being painful so it was removed. No further problems were recorded and Mrs H left hospital a day later.

A month later, Mrs H attended the hospital in relation to umbilical wound oozing; she also complained of altered sensation in her left thumb and for this was referred back to Dr T. He noted that Mrs H had had two cannula sites over her left arm where she had developed a haematoma and now had paraesthesia over her distal thumb; Dr T referred Mrs H to Dr Q, a consultant orthopaedic surgeon.

Dr Q noted neurapraxic damage to the dorsal branch of the radial nerve, and advised desensitisation exercises. A month later, improvement was noted and Dr Q noted the hyperaesthesia had settled. He further noted that there was 40% function in the dorsal branch of the radial nerve and that there was a reasonable chance that this would recover, at least to a degree.

Mrs H made a claim against Dr T for alleged substandard technique during cannulation, also alleging poor record-keeping in his failure to record two cannula insertions on the cannula chart. Mrs H claimed that when the needle was inserted into her vein, poor technique was employed, resulting in the bevel of the needle cutting through nerves and creating neuromas, causing neurological damage. Mrs H also claimed that the sensory injury had left her disabled, in that she found it extremely difficult to carry out her job.

Expert opinion

MPS obtained an expert report on breach a short time after the letter of claim was received. Professor I, a consultant in anaesthesia and intensive care, produced the report and was robust in his defence of Dr T. Professor I stated that he considered Dr T’s technique to be entirely appropriate and that he could not see any evidence of substandard care. He considered it likely that the nerve damage did arise from the unsuccessful cannulation but did not in any way reflect bad technique. Professor I also found Dr T’s record-keeping to be appropriate, as he would not expect failed cannulations to be documented.

The MPS legal team was aware that Mrs H’s own legal advisers were still to obtain their report on breach of duty, and considered that issuing them with a quick response that was supportive of Dr T would dissuade them from pursuing the matter. MPS served its expert evidence along with the letter of response a short time after the letter of claim was received.

Mrs H withdrew her allegations and the claim was discontinued.

Learning points

  • Good record-keeping is essential for continuity of care – therefore, the medical records you keep should provide a window on the clinical judgment being exercised at the time.
  • When inserting a cannula, consider using the patient’s non-dominant hand if possible.
  • It is helpful to write a report soon after an adverse event, because of the lengthy time that can sometimes pass before a related complaint or claim arises.
  • This case is a reminder that not every adverse outcome is negligent. MPS’s robust approach meant the case was dropped and the allegation withdrawn very quickly.
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