18. Mr I had surgery to his left index finger on 19 August 2019. He complains the Trust discharged him without antibiotics, did not give him enough dressings and told him to come back after two weeks for a post-operative consultation. He attended the Trust on 2 September 2019 for a post-operative review. He says the tip of his finger was so badly infected, he had to have another operation to remove it. Mr I believes the Trust should have seen him sooner.
19. During the complaint’s process, the Trust explained to Mr I that an infection of the surgical site is a potential side effect following most types of surgical procedure. It said best practice would have been to send Mr I home on oral antibiotics and to review it after one week. It said neither of these things happened. Although the Trust said it is unable to advise with certainty if antibiotics would have changed the outcome, it said it may have assisted with the prevention of the infection.
20. To help us consider this complaint, we sought advice from a hand and wrist surgeon (our adviser).
21. We considered the relevant guidance on the management of hand traumas which is the British Society for Surgery of the Hand (BSSH): Standards of care in hand trauma. In the management of open fractures, it says:
‘The patient should be referred for same day review, potentially for admission to facilitate elevation and antibiotics whilst waiting for surgery…
Timing: Within 24 hours – if definitive procedure not possible within this time a washout and closure should be done within this timeframe…
Antibiotics should be stopped at 72 hours or after definitive closure whichever is the sooner, subject to clinical judgement…
The first visit to a therapist should take place 5-7 days after surgery, before adhesions become established, unless otherwise specifically advised by the surgeon.’
22. On 14 August 2019, Mr I caught the tip of his left index finger in a van door. He fractured the distal phalanx bone, also known as ‘P3’ by some hand surgeons. A distal phalanx bone is the third of the three bones in each finger when counting from the hand to the tip of the finger. Our adviser said Mr I’s fracture type was not a ‘tuft’ fracture, so the BSSH guidelines do apply in this case. Tuft fractures are a specific fracture of the end of the P3 bone, to which these BSSH guidelines specifically do not apply.
23. Mr I attended the Trust’s ED two days after the injury. The medical records indicate he had an open wound overlying the fracture, which defines the fracture as an ‘open fracture’. The BSSH guidelines state treatment should be ‘within 24 hours – if definitive procedure not possible within this time a washout and closure should be done within this timeframe.’ The first surgical treatment was his initial operation on 19 August 2019, five days following the injury – this delay was due to the combined effect of two days delay by Mr I in attending ED and a further three days in the hospital system awaiting surgery.
24. As it took Mr I 48 hours to attend ED, our adviser said it was not possible for the Trust to meet the 24-hour target as set out by the BSSH guidelines.
25. Mr I’s medical records show he was on antibiotics until 18 August 2019 and had his surgery on 19 August 2019. This demonstrates he was on antibiotics prior to the surgery, in line with BSSH guidelines.
26. The operation notes for 19 August demonstrate there was a definitive closure of the wound in line with BSSH guidelines. The procedure involved washout and nailbed repair and splintage, which is a valid option as defined within the above guidelines:
‘…minimal procedures might include wound washout and closure with splinting of the fracture…’
27. The BSSH guidelines refer to generic open fractures and do not refer to specific fracture types. The nail bed repair carried out on 19 August effectively achieved wound coverage in the context of this open fracture.
28. There are no specific guidelines, BSSH or otherwise, that specifically recommends antibiotics should be given after definitive closure. This type of decision is made by the clinician based on judgement on a case by case basis.
29. Within the Trust’s complaint response dated 21 February 2020, it initially accepted, having sought input from its clinical team, it would have been best practice to have discharged Mr I home on oral antibiotics and seen him within one week of the operation.
30. However, during our investigation of Mr I’s complaint the Trust said prophylactic antibiotics are not necessary in open P3 fractures which was the injury in this case. Prophylactic antibiotics are given as a precaution rather than to treat an infection. In support it refers to the Pubmed: Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-analysis in the Journal of Hand surgery. It said its comment within the Trust’s letter dated 21 February 2020 - saying the Trust would have given oral antibiotics - would be for a precaution but not essential based on Pubmed’s: Prophylactic antibiotic article.
31. Our adviser considered the information provided by the Trust. They said the Pubmed article – referred to by the Trust – is not relevant in this case. This is because the research refers to patients who had received immediate washouts and not delayed presentation patients, such as in Mr I’s situation. A delay to washout was a reason to exclude patients from the studies that formed the basis of this systematic review.
32. Although the Pubmed article is not relevant in this complaint, the BSSH guidelines suggests antibiotics should be stopped after definitive closure. Given there were no documented features of infection at the first washout surgery on 19 August 2019, our adviser said it was reasonable for the Trust not to prescribe Mr I with antibiotics afterwards.
33. We understand Mr I’s concern that he was not prescribed antibiotics following surgery on 19 August, especially after getting an infection and having further surgery where he lost the tip of his finger. We have considered the relevant evidence, including his medical records and our clinical advice. The BSSH guidelines say antibiotics should be stopped after definitive closure, subject to clinical judgement. As the Trust achieved definitive closure and without evidence to show there was an infection, it was reasonable for the Trust not to prescribe Mr I with antibiotics following his initial surgery. There are no failings in this part of Mr I’s complaint.
34. We have also considered whether the Trust provided Mr I with enough wound dressings when it discharged him on 19 August 2019. There are no specific clinical standards or guidance which refers to the number of dressings that should be provided to a patient on discharge. Based on the evidence, the Trust dressed Mr I’s injury after his surgery and provided him with an extra dressing. We consider this was reasonable action by the Trust and does not indicate a failing. Once discharged, Mr I had the option to attend his GP if he had concerns about further dressings.
35. Following Mr I’s surgery on 19 August 2019, the Trust arranged a post-operative review two weeks later – 2 September 2019. BSSH guidelines says:
‘The first visit to a therapist should take place 5-7 days after surgery, before adhesions become established, unless otherwise specifically advised by the surgeon.’
36. Mr I did not receive a visit to a therapist within 5-7 days of his procedure which is not in line with the above guidelines. This is a failing on the part of the Trust.
37. Where there are failings, we then consider the impact claimed to have been suffered as a result of this. We also consider the actions taken by the organisation in response. In this case we have considered the impact of the delay in being reviewed post-operatively.
Impact
38. Mr I says the tip of his left index finger was so badly infected by the time he was seen on 2 September 2019, he had to have another operation to remove the tip of his finger.
39. Based on the medical evidence, our adviser cannot say whether the infection would have been evident had the Trust seen Mr I within 5-7 days after surgery. We cannot conclude the delay in seeing Mr I caused the loss of the tip of his finger. This is because we cannot establish an evidence-based link between the delay and the progression of the infection. However, what we can say is the Trust missed an opportunity to identify if there was any infection sooner than it did. We recognise this leaves Mr I in a position where he will never know what the outcome to his finger would have been had he been seen sooner, causing frustration and upset. This in itself is an injustice, and we go on to consider what actions have been taken by the Trust to put this right.
Outcome:
40. Based on our Principles for Remedy (our Principles), where there have been failings leading to an injustice, the public organisation should try to offer a remedy that returns the complainant to the position they would have been otherwise.
An appropriate range of remedies will include:
· An apology, explanation and acknowledgement of responsibility.
· Remedial action, i.e. service improvements to minimise the risk of this happening again.
· Financial redress.
41. The Trust has acknowledged it should have seen Mr I after one week of the initial surgery, not two and has apologised the outcome of his treatment was not successful and led to the removal of the tip of his finger.
42. The Trust has also taken action to reduce the potential of this failing recurring again. It said a duty hand consultant is now available to provide advice. It explained not only is there consultant supervision available for these procedures, but they also have oversight of all patients seen for hand trauma over this period. They can advise on appropriate care and follow up.
43. Although the Trust has acknowledged the failing, apologised for the impact caused and put service improvements in place, we do not consider this goes far enough. Based on our Principles and our guidance on financial remedy, we consider financial redress is appropriate for the impact caused. We have gone onto consider this in our recommendations.