A pensioner has died after getting a routine vitamin jab because a nurse failed to clean her skin before administering it.
Patricia Lines died less than a week after getting a Vitamin B12 injection into her shoulder, a coroner’s court has heard.
The 77-year-old was taken to hospital where the infection worsened due to bacteria from her skin being pushed deeper into the tissue by the jab.
It was heard the nurse was following current national guidance and did not clean it because there was no ‘visibly dirty skin’.
But now, assistant coroner for County Durham and Darlington, Rebecca Sutton, has issued a warning over the current guidelines and urged nurses to use ‘common sense’ and clean patients’ skin before administering jabs.
Patricia Lines tragically died less than a week after getting a Vitamin B12 injection into her shoulder. Pictured: A stock image of a vitamin B12 vial and syringe
Writing to the UK Health Security Agency, Department of Health and Social Care and NHS England, she said alcohol wipes were a ‘cheap’ and risk-free way to prevent similar deaths.
At her inquest earlier this month, it was heard she had a Vitamin B12 injection into her right shoulder on October 17 last year.
The next day she became ‘unwell’ and was taken to hospital where she was found to be suffering from a Strep A infection.
Despite the best efforts of staff, her condition continued to deteriorate and she died on October 23.
A post-mortem examination found the ‘most likely source’ of the invasive infection was the injection as it was likely ‘bacteria was present on the skin at the time’ and pushed in deeper by the needle.
A jury found her death to have been caused by septicemic shock and delivered a verdict of accidental death.
In a Prevention of Future Death report, Ms Sutton told of her concerns.
‘The nurse who administered the injection gave evidence that she did not clean the skin prior to administering the injection,’ she wrote.
‘She did not do so because she was following both her training (she quoted from an NHS e-learning module on administering intramuscular injections) and national guidance in the form of a document titled ‘Immunisation Against Infectious Disease/The Green Book.’
She pointed out a section from it which says ‘if the skin is clean, no further cleaning is necessary. Only visibly dirty skin needs to be washed with soap and water’.
It goes onto say it is ‘not necessary’ to disinfect the skin, with evidence that while alcohol wipes reduce bacteria, disinfecting ‘makes no difference to the incidence of bacterial complications of injection’.
Ms Sutton continued: ‘The evidence that I heard at the inquest included that alcohol wipes are relatively cheap and their use does not give rise to any significant risk.
‘I note that the Green Book states that cleaning the skin with alcohol reduces the bacterial count.
‘Common sense would seem to suggest that reducing the bacterial count would reduce the risk of bacteria being inadvertently introduced into the deeper tissues during an injection.
‘Whilst it is noted that the Green Book also makes reference to there being evidence that disinfecting makes no difference to the incidence of bacterial complications, it is also noted that the literature quoted is now over 20 years old.’
She added: ‘In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action.’
Ms Sutton told the recipients of the report they are under a duty to respond by December 20.