The Royal Marsden NHS Foundation Trust

3.Mr E complains that in September 2023, staff at The Royal Marsden NHS Foundation Trust did not correctly insert a cannula during a PET scan.

4.Mr E says this caused fluid to leak into his hand and body, which left a large lump in his hand. He explains he has been in significant pain since the events, and he now suffers from burning sensations, spots and rotting joints. Mr E says he now has two balls of clear fluid in his spine and has been given a diagnosis of Spinal epidural lipomatosis (SEL). Mr E feels he does not have SEL, and the balls of fluid in his spine are a result of the cannula fluid leaking into his body.

5.Mr E wants to understand what happened and whether something went wrong. He would also like the Trust to pay him a financial remedy.

6.Mr E has been under the care of the Trust for a significant amount of time.

7.In September 2023, Mr E attended the Trust for a PET scan. Mr E says that the clinician carrying out the scan incorrectly inserted a cannula in his hand which caused the radioactive tracer (fluorodeoxyglucose – a mildly radioactive liquid used in PET scans to visualize and measure activity of tissues and organs) to leak into his hand and body.

8.Mr E raised a complaint with the Trust in March 2024 and received a final written response in July 2024.

12.Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this, and we have not found any indications that something went wrong.

13.Mr E is unhappy with the PET scan he had in September 2023. He explained that straight after the PET scan, a large lump was left on his hand from where the cannula had been. He also told us that since the events, he has been in significant pain and has suffered from burning sensations, spots and rotting joints.

14.Mr E also explained that he now has two balls of fluid in his spine and has been given a diagnosis of SEL (a rare disorder where excessive fatty tissue grows in the spinal epidural space). He thinks that he does not have SEL and feels the problems he is having in his spine are a result of the PET scan in September 2023. Specifically, Mr E feels the radioactive tracer fluid used in the PET scan leaked into his body. We are very sorry to hear this and we acknowledge the impacts these events have had on Mr E.

15.In the complaint response, the Trust apologised that the cannulation process during Mr E’s PET scan caused him pain and discomfort. It explained the member of staff who placed the cannula no longer works at the Trust, so it was unable to ask them for comments about the situation. The Trust apologised that Mr E was not given more attention after he complained about the discomfort in his hand.

16.The Trust explained that the lump on Mr E’s hand could have been a result of the radiopharmaceutical tracer used to perform the PET scan leaking into the subcutaneous tissue in his hand. It said the tracer disappears from the body after six hours and does not have any side effects. The Trust also explained that cannulas in general can cause bruising and lumps which should disappear after four days.

17.The Trust said that the tracer used in Mr E’s PET scan was fluorodeoxyglucose (FDG) which is processed by the body in a similar way to sugar. It acknowledged the symptoms Mr E has been suffering with since the PET scan, but confirmed those symptoms were more than likely not related to the PET scan in September 2023.

18.There are no specific relevant guidelines in relation to clinicians inserting a cannula for a PET scan.

19.Our Principles of Good Administration state organisations must act in accordance with recognised quality standards, established good practice or both when delivering clinical care. Therefore, in this situation, we will use the professional judgement of our adviser which is based on established good practice.

20.Our adviser told us that the biggest risk of a PET scan is a non-diagnostic scan, as this would necessitate a repeat scan and a potential delay in diagnosis. The PET scan from September 2023 was considered a fully diagnostic scan. Furthermore, when the scan images were reviewed again following Mr E’s complaint, the scan was still considered fully diagnostic.

21.Our adviser told us that it is possible that at the time the cannula was removed, blood leaked from Mr E’s vein, causing the visible lump on his hand. Our adviser explained that this could happen with any blood test or cannulation and requires pressure over the small hole in the skin to avoid any bruising. We are very sorry that this happened in Mr E’s case, and we understand the lump on his hand resolved on its own shortly after the PET scan. We understand Mr E’s main concerns are around the symptoms he has been suffering from since the PET scan.

22.The tracer that was used in Mr E’s PET scan was fluorodeoxyglucose. Our adviser explained this is known as a tracer as it involves a tiny, trace amount of a radioactively labelled substance, which in this case was a version of a naturally occurring sugar in the body which is required for energy. Our adviser told us that it is impossible for someone to have a reaction to this tracer and there is no possible association or connection to SEL. Our adviser is of the view that the symptoms Mr E has been suffering from are not related to the PET scan.

23.We acknowledge Mr E was in pain and discomfort during the PET scan and was left with a lump on his hand. We understand this must have been distressing for Mr E. As it is possible for blood to leak from someone’s vein during any blood test or cannulation, we do not consider there to be any indications of failings here.

24.Regarding the other symptoms Mr E has been experiencing since the events, we do not consider these are a result of an erroneous PET scan or the tracer leaking into his body. We do however acknowledge Mr E’s concerns around this, and we hope he is reassured by what we have seen.

25.In summary, we understand that Mr E had a difficult experience during the PET scan in September 2023 and has been suffering with many symptoms since the events. We acknowledge how difficult this situation has been for him. Our investigation has shown no indication the cannula was not inserted in line with good clinical practice. We have not seen any evidence to suggest the ongoing symptoms Mr E is experiencing are due to the PET scan. For these reasons, we shall not consider this complaint further. We are sorry if our decision causes any further distress to Mr E, and we wish him all the best in the future.

1. We have carefully considered Mr E’s complaint about The Royal Marsden NHS Foundation Trust (the Trust). We understand the importance of Mr E’s complaint and we are sorry to learn Mr E has remained in pain since the events. We appreciate this experience has been difficult for Mr E, and we thank him for giving us the opportunity to look into his complaint.

2.We have looked at what Mr E told us and the evidence we have received from enquiries with the Trust. We have investigated the complaint regarding Mr E’s Positron Emission Tomography (PET) scan which happened in September 2023. We have seen no indications that anything went wrong during this scan. We hope Mr E is reassured by what we have seen.