3. Miss E complains on behalf of her son, O, about the care and treatment he received when he was transferred to the Trust for surgery. Specifically, she complains that when he returned to the previous hospital following his surgery, he had burn-like wounds to his bottom.
4. Miss E says this caused her and her partner great distress and her son experienced a great deal of pain, with him having to be treated with morphine.
5. Miss E wants an explanation of what happened and service improvements.
6. O was born several weeks premature. Unfortunately, he had a problem with his right testicle which required a surgical review that could not be carried out at the hospital he was born in.
7. So, the day after his birth, O was transferred to the Trust for the surgical review. Staff there decided O would undergo surgery and notes from the procedure suggest it went well, without issues. O remained in the Trust’s care and there is no record to suggest he had an injury to his bottom.
8. Following the surgery, the Trust discharged O, and an ambulance (operated by a different NHS trust) transferred him back to the hospital where he was born. The ambulance crew did not provide any care to O, their role was simply to transfer him.
9. Not long after his return to hospital, staff noticed O had a burn like injury on his bottom.
13. Miss E complains that when O returned to the hospital after having surgery at the Trust, he had burn-like wounds to his bottom. In response to her complaint, the Trust was unable to explain how O sustained his injury and did not accept that it occurred whilst he was in its care.
14. We asked both of our clinical advisers how O’s injury may have occurred. They said the injury was consistent with chemical burns occurring because of pooling of chemical cleaning fluid.
15. The only times such fluids were used was whilst O was undergoing surgery in the Trust’s care. Therefore, it seems likely O sustained his injury during surgery. Our neonatology adviser explained that it would not be unusual for an injury like this to occur but only become visible a few days later.
16. Our surgical adviser said staff used a cleaning fluid when they injected O’s spine with anaesthetic prior to his surgery. They either did not document which fluid they used or have not provided us with the relevant documentation. So, we asked the Trust what staff usually do in these circumstances.
17. The Trust told us that staff use chlorhexidine, which they apply whilst the infant is lay on their side. The Trust said that as such, any fluid would pool at the infant’s back, not their bottom.
18. NICE guidance states that chlorhexidine can cause severe chemical burns when used on premature infants like O. The advice is to use it sparingly, monitor for skin reactions and to not allow it to pool. This is what staff should have done when using chlorhexidine and the Trust has its own policy to ensure staff do this.
19. The Trust has no records to indicate how much chlorhexidine was used, what action staff took to monitor for a skin reaction or to mitigate against potential pooling of chlorhexidine. We would have expected to see this in line with GMC guidance given the serious risks associated with its use.
20. In the absence of any evidence to show staff acted in line with the BNF, and in view of the fact O sustained an apparent chemical burn, which can happen when chlorhexidine is used, it is more likely than not that staff did not act in line with NICE/BNF guidance when using chlorhexidine. This falls so far short of what should have happened that it amounts to a failing.
21. Given that O suffered an injury consistent with chemical burns, on balance, we consider this was caused by pooling of chlorhexidine. This, undoubtedly, would have been painful for O and distressing for his parents. This was an injustice to them, seemingly as a result of the staff’s failure to either use the chlorhexidine sparingly, monitor O for skin reactions or allow it to pool – or a combination of these factors.
1. The Trust failed to mitigate against the risks of using a chemical cleaning fluid that is known to cause severe burns in premature infants when it carried out O’s surgery. It is likely the fluid pooled at O’s bottom which caused a burn like injury that was painful for him. It would also have been distressing for his parents to see this. The Trust has failed to put this right, so our decision is to uphold this complaint.
2. We recommend that the Trust develops an action plan to address the failings we have identified in this report and the impacts they had.
22. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.
23. Our principles say that public organisations should look for continuous improvement and should use the lessons learned from complaints to make sure they do not repeat maladministration or poor service. In line with this, we recommend that within three months of the date of our final report, the Trust should develop an action plan that addresses the issue we have identified and the steps needed to prevent it from occurring again. The Trust should delegate a staff member to ensure the plan is developed on time and provide us and Miss E with a copy of the plan once completed. We note that the Trust already has a policy in place to ensure staff follow the principles set out in NICE/BNF guidance, so the action plan should ensure this happens consistently and that staff record details of the care they provide in clinical records.