"Distress after a botched CT scan"

About: Huddersfield Royal Infirmary Yorkshire Ambulance Service NHS Trust

Posted by upset calderdale (as a relative),

My mother is 88 years old and has diverticular disease. In the past three months, worryingly, she has had three emergency admissions to the hospital via A&E, with severe sudden abdominal pain.

The first episode three months ago required abdominal surgery; she recovered amazingly quickly and was very relieved. The second episode a month ago came as a shock; it was treated successfully with intravenous antibiotics. The recent episode last week also was treated with IV antibiotics; she again has recovered well.

However, six days ago when I arrived to see her on her fifth day in hospital, she was in distress following a set of unfortunate events arising in her treatment the previous day. She, my sister and I are very thankful that she has in fact recovered through the antibiotics that were given to her; but I feel I need to draw your attention to what happened along the way.

On her fourth day in the ward she was sent for a CT scan; there it was discovered that she had been fitted with the wrong size of canula (blue), despite clear written instructions describing which colour of canula should be inserted (green or pink); repeated attempts in the scan suite to fit a canula failed; there was ‘panic’ (my mother’s observation); a canula ‘tissued’ and CT scan dye was painfully injected into the muscle of her arm (which later swelled up); the scan was eventually cancelled because too long had elapsed since drinking the ‘gloop’ (contrast fluid) and was rescheduled for the following day.

The following day my mother was administered a further stomachful of gloop, which she was beginning to dread, and fitted with another canula (her arms were black and blue - some of these from her IV treatment a month earlier) and the scan was carried out. Feeling sick my mother was given an anti-emetic (cyclizine) to which she reacted badly, hallucinating. When I arrived for evening visiting she was in a state of distress, wanting to vomit and afraid to, hallucinating, with a swollen arm, chin in a sick basin, head in her hands, in utter misery, unreachable. Eventually she sicked up some bile and brightened a bit. But my sister and I left, worried and shocked.

We appreciate that a canula can be hard to insert, especially when a patient is tense and anxious and the veins have contracted; I know that ‘tissuing’ is something that happens. But for an old lady, four days in hospital - again :-( - not knowing how she would get better and fearing further surgery, to have dye injected into her flesh, ‘panic’ around her in the CT suite, and not just one but two stomachfuls of contrast fluid to cope with, is an awful story; even before the disorientation resulting from the anti-emetic. She really looked as if she was ready for the end to come.

Two days later the antibiotic had begun to work; six days later she was discharged; seven days later she has been to the shops (with help) and eaten normal meals at home. She’s a tough old boot.

We all have our fingers crossed that there isn’t another episode. My mother hopes against hope that she doesn’t have to have any more CT scans. And she’ll refuse any more cyclizine: apart from its horrid effect on her mind, it apparently (Boots Web MD website) can raise pressure in the eyes; she is an out-patient in the glaucoma clinic at the sister hospital.

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Responses

Response from Anne Catchpole, Assistant Director of Involvement, NHS Calderdale on 03/11/2011 at 10:30

Thank you for your posting. I am very grateful to you for taking the time to feed back about your mothers experience to us.

I am sorry to hear that you have had a difficult and worrying time and understand how you might feel let down by your care.

I will pass your comments on to the hospital so that they can investigate and feed back to you.

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Response from NHS Calderdale on 03/11/2011 at 11:48

Posted on behalf of Calderdale & Huddersfield NHS Foundation Trust

Thank you for providing feedback on your experience of using our services and we are sorry that you have concerns regarding the care provided to your mother. Our Patient Advice Team would be happy to take these concerns forward for you and can be contacted as follows:

Tel: 0800 013 0018 - Mon - Fri 9 am - 5 pm

patientadviceandcomplaintsservice@cht.nhs.uk

Many thanks

Jill Pell

Senior Patient Advice & Complaints Co-ordinator

Calderdale & Huddersfield NHS Foundation Trust

Huddersfied Royal Infirmary

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Update posted by upset calderdale (a relative) on 04/11/2011 at 17:38

Thanks for inviting us to contact you Jill.

My sister and I have no wish to file a complaint. We simply want to highlight the possibility of things going wrong in the way they did for our mother with the CT scan and cyclizine, in the hope that suitable steps might be taken to reduce the likelihood of such things happening to others.

If you believe that a formal complaint will help bring about changes, we'd consider that step But that's not our intent, and we hope that this posting will be enough to trigger some reflection.

Response from NHS Calderdale on 08/11/2011 at 08:41

Posted on behalf of Calderdale & Huddersfield NHS Foundation Trust

Thank you for your response. I confirm you do not need to go through a formal complaint process. Your comments will go back to the relevant service manager for learning and improvement and will be monitored as part of our wider patient experience improvement work.

Many thanks

Jill Pell

Senior Patient Advice & Complaints Co-ordinator

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