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Health chief admits failure to comply with infection control procedures after nurse used contaminated IV line on ‘horrified’ cancer patient

30 Jul 2021 4 minute read
An intravenous line being fitted. Photo by Official Travis AFB, Calif. is licensed under CC BY-NC 2.0.

Richard Youle, local democracy reporter

A nurse dropped an intravenous line on the floor of a hospital ward which had a major infection issue and then used it on a patient with advanced cancer, Swansea Bay University health board members were told.

It then emerged that the patient, a mother of two young daughters, tested positive for a hospital-acquired infection before she was discharged – but this result wasn’t shared with her, her GP or the oncology department where she subsequently began a course of palliative chemotherapy.

The story of the patient, Annabel, who died on January 19, 2020, was told in a video by her husband and shared at a health board meeting.

The husband said his wife was due to undergo a major operation for stomach cancer when the intravenous line incident occurred.


“She had the trauma of seeing an agency nurse putting the line in her mouth and then dropping it on the floor and than applying it back,” he said.

Not long after, redness appeared in the area in question and the line, which delivered nutrition to his wife, had to be removed in theatre.

To make matters worse, said the husband, the ward was “in closure because of a major infection at the time”.

He said the dropping of the equipment and then the use of it was horrific for his wife.

He said she was considered well enough to have the operation, but sadly surgeons were unable to do what was needed.

The husband said his wife was being swabbed regularly for the presence of infection, with the final swab the day before her discharge from the un-named hospital in Swansea Bay.

He said the couple then went straight to see her oncologist at Singleton Hospital, where a course of palliative chemotherapy was agreed.

Later his wife became unwell and returned to Singleton Hospital.


The husband said it was only then that a nurse told her that the final swab had come back positive.

He said in the meantime she had had chemotherapy sessions next to other cancer patients.

He went on: “I could visibly see the relief in her face when she went into Ty Olwen (hospice) as she hadn’t felt safe where she had been in her journey over the previous three months.

“We were able as a family to come together and have meaningful, difficult, sad discussions.”

His wife, she said, was able to tell her daughters how much she loved them on their final visit.

Christine Williams, the health board’s interim director of nursing and patient experience, said there had been a failure to comply with standard infection control procedures.

She said she had met the patient while she was alive, and also her husband on a number of occasions, and that the couple just wanted lessons to be learned from what happened.

“Specific action has been taken in relation to the agency nurse,” said Ms Williams.

“It was just basic failure to comply with basic infection prevention control standards, which resulted in Annabel contracting this very significant infection, which was very difficult to treat.”

Ms Williams said the health board at a wider level was not making “significant headway” into hospital-acquired infections but that she was confident the situation would improve over the next six months, partly because it was a key quality priority for the health board.

She also said other health boards in Wales were seeing increases in some infections, and that a Wales-wide group was looking into this.

Executive medical director Dr Richard Evans said such infections, particularly C. difficile, were driven by the way in which antibiotics were prescribed, and that it was important in hospital settings that they were given in tablet form wherever possible.

Mwoyo Makuto, chief officer of the area’s community health council – a patient watchdog – asked if anything was being done to make it easier for patients to challenge staff if they felt something was wrong.

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Stephen Owen
Stephen Owen
2 years ago

Very bad, a failure in the most basic of infection control.

2 years ago

It should be a fundamental tenet of primary healthcare that you don’t do anything likely to make the situation worse.

If primary healthcare staff are under such pressure that patient wellbeing comes second to cost-saving and attaining targets then there is something seriously wrong in our NHS, something that Eluned Morgan needs urgently to focus on.

Huw Davies
Huw Davies
2 years ago
Reply to  defaid

This happened in secondary healthcare (primary is a GP surgery) and still using equipment that’s been dropped on the floor is nothing to do with pressure, it’s just plain poor care.

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