Repositioning
17. Mrs S was admitted to the hospital after spending almost two days in the same position. Increased pressure on one area of the body can cause that area of tissue to be starved of oxygen and blood. Over a period of time, this tissue can become infected.
18. Mrs S’s pressure sore was ‘ungradable’ on admission. This describes full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (a tan/brown or black leathery layer) in the wound bed. Until this slough or eschar is removed to expose the base of the wound, the true depth cannot be determined.
19. When a patient has an ungradable pressure sore, repositioning is one element of pressure area management. National and international guidance states that the frequency of repositioning should be determined on an individual basis, taking into account the patient’s general medical condition, skin condition and comfort. It should be prescribed by a tissue viability nurse (TVN).
20. NICE guidance states that clinicians should ‘encourage adults who have been assessed as being at high risk of developing a pressure ulcer to change their position frequently and at least every 4 hours’.
21. The matron prescribed a repositioning plan on 30 April which was based on Mrs S’s individual needs, in line with the relevant guidance. The matron prescribed two hourly positional changes and advised that she should sit out for only one hour at a time. This is intended to reduce direct pressure to the pressure sore.
22. Mrs S was assessed by the TVN on 9 May 2019. The repositioning was relaxed a little to accommodate a change of position every two to four hours. The repositioning plan was in line with the national guidance. The skin care charts indicate Mrs S was turned every two to four hours throughout her admission. This was also reflected in the Trust’s response.
23. The Trust also stated that on a ‘few occasions’ Mrs S’s position was not changed for up to six hours. We recognise this caused Miss S concern.
24. We hope it will reassure her to learn Mrs S was undertaking other activities during some of these occasions. For example, using the commode, or in physiotherapy, surgery or medical and specialist reviews. We do not consider that there was a failing on these occasions.
Time taken to arrange MRI
25. The GMC’s guidance on Good Medical Practice says doctors ‘must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
a) adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b) promptly provide or arrange suitable advice, investigations or treatment where necessary c) refer a patient to another practitioner when this serves the patient’s needs.’
26. Pressure area detection and monitoring is usually carried out by the nursing team. The physicians would be guided by the tissue viability nurse (TVN), a specialist in that area, in terms of whether further action, such as a surgical review and an MRI, is required.
27. The Trust referred Mrs S to a TVN on the day it admitted her. She did not have osteomyelitis at that point.
28. Mrs S had been experiencing diarrhoea since 30 April and was prescribed antibiotics (Flucloxacillin) for her cellulitis. The Trust started Mrs S on intravenous antibiotics from 2 May onwards (initially Teicoplanin and later Gentamicin).
29. From 5 May, it was clear her condition and blood tests were getting worse despite her being on antibiotics. There is no guidance on when an MRI should be arranged so it is not possible to say what the ‘right time’ would have been. The Trust could have considered arranging the MRI from this point onwards. It is a failing that this did not happen.
30. Mrs S’s bloods were noted to be worsening on 8 May. She was seen by the TVN on 9 May. The TVN did not recommend an MRI or surgical review at that point. The Trust decided to arrange an MRI on 14 May as Mrs S’s infection markers were still not improving.
31. The Trust carried out the MRI three days later. Our physician adviser said this was a reasonable timescale, though it would have been beneficial to do this sooner. The Trust could also have asked the surgeons to review Mrs S whilst waiting for the MRI. It reported the MRI promptly afterwards.
32. As we have identified a failing, we considered what impact this had with our surgical adviser. If the Trust had carried out the MRI soon after 5 May, it might not have shown all of the findings at that point. For example, the osteomyelitis that the MRI on 17 May identified.
33. Had the MRI been carried out three or four days sooner than it was, it is likely it would have shown the same results. Therefore, Mrs S could potentially have been in theatre a few days sooner than she was.
Time taken to arrange surgery 34. The involvement of a TVN is a standard part of wound management. In some cases, particularly where the wound is small, it can get better through medical management and the input of a tissue viability nurse. This can include the use of dressings which autodebride the wound. Carrying out surgical debridement when it is not necessary can be harmful, or at least expose the patient to an unnecessary general anaesthetic.
35. The NICE guidance says ‘Assess the need to debride a pressure ulcer in adults, taking into consideration: the amount of necrotic tissue, the category, size and extent of the pressure ulcer, patient tolerance, and any comorbidities.’
36. The MRI showed the early stages of osteomyelitis and the orthopaedic surgeons decided antibiotics could manage this condition in the initial phase. The microbiologists had provided advice about the use of antibiotics.
37. When the general surgeons reviewed Mrs S’s wound, they decided they needed to debride it. They arranged an anaesthetic assessment to determine her fitness for surgery and to decide if she needed medical optimisation prior to surgery. This was in line with the NICE guidance.
38. The surgeons needed to assess the risks before the surgery took place. The Trust carried out an anaesthetic assessment on 19 May. Mrs S had a necrotic sacral sore and the Trust categorised her debridement surgery as expedited. The surgery took place within days of the decision to operate and this was in line with the NCEPOD Classification of Intervention.
39. The Trust carried out the surgery on 21 May. The records indicate it had planned to do so the day before. In its initial response, the Trust said the reasons for this delay were unclear. It later said this was most likely due to theatre capacity.
40. The Trust could potentially have carried out the debridement 24-48 hours earlier. There is a failing in relation to this. We considered what the impact of this was.
41. Mrs S’s CRP levels (a marker of inflammation) had been consistently high in the week prior to her surgery. Whilst she could have gone to theatre a few days earlier, there was not an acute sudden deterioration in her general medical state during that time period. Antibiotics were controlling her sepsis effectively.
42. Mrs S was very unwell during the operation and developed fast atrial fibrillation (an irregular heart rate) with a low blood pressure.
43. Her body’s reaction to the trauma of the operation reflects the size of the wound that the Trust debrided. This is related to the amount of dead tissue which was present. The majority of this would have developed when Mrs S was stuck in one position at home with continuous pressure on the area.
44. Taking all of this into account, it is likely that even if the Trust had requested surgical input sooner or arranged the surgery sooner, it would not have had an impact overall to Mrs S’s survival. We hope this will provide some clarity to Miss S about the care her mother received.
Communication with the family 45. In line with the GMC guidance, doctors must give patients the information they want or need to know in a way they can understand. They must be considerate to those close to the patient (or those people with the legal authority to make healthcare decisions on a patient’s behalf) and be sensitive and responsive in giving them information and support.
46. Miss S feels the Trust's communication with her family was poor. There is little documentation about the communication with Mrs S’s family. As she was in poor health, it is possible Mrs S may not have been taking in all of the information the Trust was giving to her.
47. The records indicate the situation was dynamic. It is likely the Trust did not have a definitive plan until all of the relevant clinical specialisms had provided input on how to manage Mrs S. It would have been appropriate for the Trust to provide an update to her next of kin at that point. We consider it a failing that it did not do so.
48. The Trust has acknowledged the communication from the medical team with the family ‘could and should have been more pro-active’. It said ‘too much reliance was placed on [Mrs S] to convey to [her family] the need for a conversation with the medical team.’ We agree with this.
49. The Trust has already acknowledged its poor communication and apologised for its impact. Our view is that the Trust has not gone far enough as it has not shown it implemented any learning. We are making recommendations to put this right.
Complaint handling 50. Our Principles of Good Complaint Handling say organisations should deal with complaints promptly, avoiding unnecessary delay, and in line with published service standards. They should keep the complainant regularly informed about progress and the reasons for any delays. The NHS Complaints Regulations say organisation should complete an investigation and send the complainant a response within six months.
51. Miss S says the Trust’s responses to her and the coroner were delayed. She says the Trust should have provided a response within 25 working days. The Trust’s website says ‘In most cases, we aim to respond to you in full within 25 working days. However, if your complaint is particularly complex or involves other organisations, we may require more time to respond. Where possible, we will identify this at the outset.’
52. Miss S made her formal complaint on 1 June 2019. The Trust responded approximately 12 weeks later, on 23 August. This was significantly longer than the Trust’s target response time of 25 working days. The Trust said this was because it needed to request additional information it did not initially have.
53. Miss S contacted the Trust again on 4 September 2019. The Trust told her on 12 September that it would wait for the witness statements which had been requested as part of the inquest process then respond to all of her queries at once.
54. Miss S chased the Trust for an update on 30 October. The Trust said it had a draft response which needed to be reviewed and signed. Miss S followed this up on 8 November and after further correspondence, the Trust sent its further response on 6 December 2019.
55. Overall, the Trust responded to Miss S’s complaint with the six-month timescale set out in the NHS Complaint Regulations. However, we have seen no evidence that the Trust kept Miss S updated about progress on her complaint. This was not in line with our Principles. We consider this a failing in its complaint handling.
56. Miss S is also concerned the Trust’s response to her complaint was not consistent with the response it sent to the coroner. We expect organisations to be open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations, and reasons for their decisions.
57. We expect organisations to act fairly towards staff as well as complainants. This means ensuring members of staff know they have been complained about and, where appropriate, have an opportunity to respond.
58. The Trust has acknowledged there were some inaccuracies in its initial response. In response to Miss S’s concerns about a difference between the Trust’s initial response and the report provided to the coroner, it said ‘there were two different assessments being carried out with different outcomes in terms of clinical management plans’.
59. It explained the soft tissue infection and necrosis were assessed by the general surgeons. The osteomyelitis affecting the bone was assessed by the orthopaedic team. The Trust told Mrs S the staff concerned would provide additional information to the coroner to help clarify this. This is a potential shortcoming in the Trust’s approach. It would have been better if the Trust had clearly addressed this.
60. We recognise part of Miss S’s concern is the Trust’s conclusion that earlier intervention would not have altered the outcome for her mother. As we have explained in this report, we share this view. We hope our investigation will help Miss S better understand the care the Trust provided to her mother.