NHS Lothian ordered to apologise after patient died from infection linked to cannula

NHS Lothian has been ordered to apologise to a patient’s family after they developed a serious blood infection while being treated in hospital.

The Scottish Public Services Ombudsman found failings in the nursing care provided to the patient, including the care of an intravenous cannula, which was later found to be infected.

The patient, referred to as A in the report, had been admitted to hospital after becoming unwell. Clinicians diagnosed a urine infection and kidney problems, and A was given intravenous fluids through a peripheral venous cannula (PVC).

A few days later, the PVC showed signs of infection, and tests confirmed that A had developed a Staphylococcus aureus bacterium (SAB) infection.

The infection was assumed to have arisen from the use of the PVC.

A’s family raised concerns about how the infection was managed, as well as the nursing care surrounding the cannula.

They also complained about how NHS Lothian investigated the incident through an adverse event review.

Following an investigation, the Ombudsman found that the medical care and treatment provided to A was reasonable.

Medical staff carried out regular and detailed reviews of A’s condition, managed the SAB infection in line with relevant guidance and maintained frequent communication with the family.

However, the Ombudsman found that the nursing care was not reasonable in several areas.

There were gaps in records relating to the care and maintenance of the PVC, with some sections incomplete or left blank.

Nursing care also failed to meet relevant guidance for PVC care, while the investigation identified failings in skin assessment and the assessment of a wound on A’s arm.

The report noted that A was already seriously unwell when they were admitted and was likely suffering from organ failure as well as an antibiotic-resistant urinary tract infection.

It said A may not have survived those conditions, but the additional SAB infection made it more likely that their condition would deteriorate and less likely that they would survive.

The SPSO report read: “Taking all of the above into account, I did not uphold C’s complaint about the standard of medical care and treatment provided to A.

“I did uphold C’s complaint about the standard of nursing care and treatment provided.”

NHS Lothian has now been ordered to apologise to A’s family for the failings identified in the nursing care and the handling of the review.

The board has also been told to review its systems and training for nursing staff covering PVC care, SAB infections, record-keeping, skin assessment and wound care.

Audits must be carried out to ensure staff are following relevant guidance and meeting record-keeping requirements.

The board has also been asked to review its procedures for adverse event reviews and ensure they comply with the national framework.

It must provide evidence of its apology by October 23, with the wider improvement measures due by January 25, 2027.

NHS Lothian has been approached for comment.