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A red electrocardiogram
A red electrocardiogram
A red electrocardiogram

Case Study: Iron Extravasation Injury in Iron Deficiency Anaemia Treatment

To maintain confidentiality names have been changed and no reference is made as to the Defendant.



Iron deficiency anaemia (IDA) is a common haematological condition characterised by inadequate iron levels, which impairs haemoglobin production and reduces oxygen delivery to tissues. IDA presents clinically with symptoms such as fatigue, shortness of breath, and pallor. Management strategies range from dietary modification to pharmacological interventions, including oral and intravenous iron therapies.


Brief Case Presentation

Mrs Jeffries, a 45-year-old female with a history of significant menorrhagia leading to IDA, was subjected to intravenous iron therapy after failing to tolerate oral supplements due to severe gastrointestinal side effects. Her medical history and previous treatment responses necessitated a careful approach to her ongoing care.


Incident Description

During the administration of an iron infusion at a local outpatient clinic, Mrs Jeffries suffered a significant extravasation injury, which resulted in immediate severe pain and extensive, permanent brown staining of her arm. This adverse event highlighted several systemic failures in patient management and care protocols.


Scott Harding-Lister (Nurse Expert) was instructed, and the following issues were identified during his investigation:


  1. Informed Consent: The process was critically flawed as Mrs Jeffries was not sufficiently informed about the potential risks associated with the procedure. This lack of informed consent was a fundamental breach. 

  2. Patient Education and Communication: There was a failure to provide essential patient education materials and adequate communication, which are vital for ensuring patient preparedness and informed decision-making. Mrs Jeffries was not told what the risks were and therefore she did not know what to look out for and when to ask for help. 

  3. Documentation and Protocol Adherence: The medical documentation was incomplete and lacked detail, reflecting poor clinical practice and non-adherence to standard protocols which could have prevented this incident.

  4. Cannulation Technique: Improper cannulation technique directly caused the tissue extravasation, indicating a need for improved training and competency in clinical procedures.

  5. Emergency Response and Policy Gaps: The response was delayed and ineffective, compounded by insufficient protocols and the absence of immediate access to intervention tools, such as a call bell system.


Outcome and Legal Implications

The case concluded with a settlement in favour of Mrs Jeffries, recognising the preventability of the injury and the multiple clinical failures. It highlighted the need for rigorous legal scrutiny of clinical practices and underscored the potential for nursing and medical liability.



This case study not only highlights a significant clinical failure but also serves as a potent reminder of the critical roles that informed consent, patient education, and adherence to clinical protocols play in ensuring patient safety and the quality of care. The incident involving Mrs Jeffries, which resulted in permanent physical and psychological damage, underscores the severe consequences of neglecting these fundamental aspects of healthcare delivery.


To prevent future occurrences of similar adverse events, it is imperative that healthcare organisations implement a multifaceted approach that includes regular training and assessment, robust policy frameworks, enhanced patient engagement, interdisciplinary collaboration, and stringent quality control and audit processes.


Scott Harding-Lister, Director at Apex Health Associates




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