Colwill v Oxford Radcliffe Hospitals NHS Trust

A hospital’s clinical decision is assessed by reference to the information reasonably available at the time, rather than with hindsight. Cannulation may be justified even where later evidence shows that it was unnecessary. However, placing a peripheral cannula near a joint without medical justification may amount to poor practice, although it is not necessarily negligent or causative of infection. A hospital may be liable where failures in documentation and communication prevent clinicians from knowing that an unused cannula remains in place. A doctor is negligent where, faced with persistent pain, swelling, fever and other signs indicating infection, he fails properly to consider infection and prescribe timely antibiotics.

The claimant contracted a staphylococcal infection at the site of an intravenous cannula inserted during her admission to hospital. The infection progressed to septicaemia, pneumonia and serious neurological injury.

The parties agreed that the cannula caused the infection, that earlier removal would probably have prevented its progression, and that antibiotics started on 25 September would probably have prevented the resulting injuries. The court determined whether the initial insertion and location of the cannula were negligent, whether it should have been removed earlier, whether the hospital’s documentation and communication system was adequate and properly operated, and whether antibiotics should have been prescribed on 25 September.

1. Insertion. The decision to insert the cannula on admission was not negligent. Although later evidence showed that the claimant was not biochemically dehydrated, the doctor had made a clinically sustainable judgment that she might be dehydrated. Blood samples were also taken through the cannula. The assessment had to be made without hindsight.
2. Location. Placement in the antecubital fossa was poor and undesirable practice. It caused discomfort and increased the likelihood of mechanical irritation and thrombophlebitis. There was no medical justification for that site, contrary to the hospital policy. However, there was no empirical evidence that the site itself materially increased the risk of infection, so the placement was not found negligent.
3. Removal and system failure. The cannula was no longer required after 22 September and should have been removed by 23 September. Its continued presence resulted from failures in record-keeping and communication. The insertion was not properly recorded, the relevant chart was kept with nursing records that doctors did not ordinarily inspect, and the nurses did not alert the doctors. Had the cannula been identified and removed on 23 September, the agreed evidence established that the infection and ensuing injuries would probably have been avoided.
4. Antibiotics. On 25 September the claimant had persistent pain, swelling, fever, malaise and other accumulating signs of infection. The judge rejected the treating doctor’s evidence that he had properly considered infection. His focus remained on the undiagnosed illness that had prompted admission. Proper consideration of the cannula-site infection should have led to antibiotics being prescribed that day. The failure was negligent and causative of the subsequent complications.
5. Judgment was therefore entered for the claimant on liability.