Trust did not arrange scans and X-rays to diagnose osteomyelitis, which led to Mrs A’s death
15. We have looked at whether there are indications the events complained about had the negative effect that the complainant has told us about. In this case Mrs U says Mrs A sadly died because the Trust did not treat her for chronic osteomyelitis. We cannot link the events complained about with the negative impacts Mrs U has claimed. We explain the reasons below.
16. Osteomyelitis is an infection of the bone marrow, which may spread to the outer part of the bone. The first mention of suspected osteomyelitis was written in the medical records following the ward round on 27 September. The PHE guidance outlines what actions should be taken to diagnose this: ‘The diagnosis of osteomyelitis usually requires a combination of a full clinical assessment, plain X-rays and further imaging (eg MRI scan, CT scan, ultra-sound), blood cultures (particularly in acute cases), bone and/or soft tissue biopsies and/or surgical sampling.’
17. We can see the Trust acted in line with the PHE guidance in arranging an X-ray. This was also in line with the GMC guidance, which says doctors should ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.
18. The Trust arranged the X-ray, but the medical records show Mrs A ‘was aggressive towards the radiologists and punched them’. It was not possible for the Trust to make a definite diagnosis as it could not take an X-ray. The Trust never formally confirmed the suspected diagnosis of osteomyelitis.
19. Our adviser told us there is a strong suspicion Mrs A had a deep infection caused by her leg ulcers, but we cannot say for certain she had osteomyelitis. The death certificate says the cause of death was ‘old age’. From this we conclude that, on the balance of probabilities, her death was due to a combination of her pre-existing conditions. We are not able to conclude that she died of chronic osteomyelitis, or that her death was avoidable.
20. We understand that Mrs U feels strongly about this, and we have carefully considered her views. We have included more about the treatment decisions later in this statement, in paragraphs 38 to 45, and we hope this brings further reassurance.
Trust dressed Mrs A’s leg with iodine dressings, the podiatry team did not visit often enough.
21. We looked to see if there were indications that the Trust using iodine dressings had the impact Mrs U told us about. She said her mother was in discomfort and pain, and this may have made the infection worse. She told us it was distressing for the family to witness this.
22. The medical records note Mrs A was allergic to iodine dressings. Our adviser told us an allergy to iodine could cause an itchy rash, swelling, or anaphylaxis, but would not make an infection worse. There is no evidence in the records that Mrs A had any of these allergic reactions or that the infection got worse because of the dressings. When the Trust stopped using the iodine dressings, any allergic reaction would also have stopped. For this reason, we have not seen any indications that the dressings made the infection worse.
23. We were sorry to hear the family were distressed when they found out iodine had been used, and we can understand their concerns. The Trust has acknowledged it used iodine dressings for ten days and has apologised for this. We think this is enough to put right the distress it caused the family.
24. We also considered whether the frequency of the podiatry team visits could have led to Mrs A’s infection getting worse. The GMC guidance says:
‘In providing clinical care you must: a. prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs b. provide effective treatments based on the best available evidence c. take all possible steps to alleviate pain and distress whether or not a cure may be possible d. consult colleagues where appropriate f. check that the care or treatment you provide for each patient is compatible with any other treatments the patient is receiving, including (where possible) self-prescribed over-the-counter medications’.
25. We think the care the Trust gave here was in line with this guidance. Mrs A was receiving regular reviews and changes to her treatment plan by the medical team that addressed the ongoing infection. The frequency of the podiatry team’s visits did not make a difference to this. For this reason, we have not seen any indications that the frequency of the podiatry team visits would have made the infection worse.
The Trust did not prescribe antibiotics for 12 weeks
26. We have not seen any evidence that Mrs U raised concerns during the complaint process that the Trust did not prescribe antibiotics for 12 weeks.
27. The law that says what we can investigate is the Health Service Commissioners Act 1993. This prevents us from investigating unless we are satisfied the complaints process has been used and exhausted, unless this was not reasonable. For this reason, we cannot look further at this part of the complaint.
28. Mrs U could approach the Trust to explain exactly what she means by this part of the complaint and ask for a response. However, it is possible the Trust may decide this is outside its time limits, and this would also be outside our time limit for investigation.
29. We have looked at the decisions about antibiotics on discharge in paragraphs 38 to 45. This may answer some of Mrs U’s concerns.
The Trust did not complete the PEACE form correctly and did not discuss this with the family
30. The PEACE form is a part of advance care planning. We looked at what happened and whether it was in line with what should have happened according to the Advance Care Planning (ACP) guidance. We did not see any indications that anything went wrong.
31. The guidance outlines the importance of helping people make decisions about what they want for future care. It emphasises the need to include family in decision making where appropriate. It does not say exactly what a doctor should write on the form, or what exactly the communication with the family should cover.
32. We can see the Trust properly completed the form in line with the guidance, as it takes full account of what Mrs A wanted. An associate physician signed the form and a consultant countersigned it. The medical records show the associate physician explained and discussed the form with ‘Mrs A’s daughter’ on 4 October, and that she was in full agreement with the decisions and what the Trust would include on the PEACE form.
33. We can see from the complaint correspondence that Mrs U says she was not involved in drawing up the plan, as outlined on the PEACE form. It is difficult to know exactly what the Trust discussed and how much Mrs U understood of the discussion as we were not present.
34. Where there is a difference in recollection, we try to find independent evidence that could help us reach a decision. However, in this instance we have not been able to identify any independent evidence. For this reason, we are not able to say what was probably discussed, agreed, or understood.
35. However, we do not see any indications of failings in communication from the information contained within the medical records. The records show a detailed conversation, in line with GMC guidance 33, which says: ‘You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’. It is regrettable that the information shared did not meet Mrs U’s needs. The Trust has been sensitive in recognising this and has apologised.
36. Mrs U also told us the form did not say her mother was in the last few weeks of her life. Our adviser explained it is not possible for doctors to accurately predict a person’s life expectancy and this is not the purpose of the PEACE form. The guidance explains the form is to allow people ‘to plan their future care and support, including medical treatment, while they have the capacity to do so.’ It explains this is especially relevant to ‘people whose mental capacity varies at different times’, as was the case with Mrs A.
37. We understand how upsetting it must have been to find out a short time later that Mrs A was at the end of her life. We hope our explanation has given Mrs U some reassurance.
The Trust discharged Mrs A on 8 October without antibiotics and with inadequate pain relief
38. We looked at whether there were signs the Trust got anything wrong in relation to antibiotics and pain relief. We can understand why Mrs U thought things had gone wrong as it was very upsetting for the family to see Mrs A in pain.
39. We compared what should have happened, in line with the guidance, with what did happen. Having done this we have not found any indications that anything went wrong in relation to this part of the complaint.
40. Our adviser explained that if it had been possible to confirm osteomyelitis, Mrs A would have required a six week course of intravenous (IV) antibiotics. It is clear from the medical records that Mrs A could not tolerate IV antibiotics and the medical team had to get an anaesthetist to insert an IV line.
41. Treatment with antibiotics would have meant Mrs A had to stay in hospital which she did not want. This would have been contrary to ACP guidance which says, ‘people may make choices that seem unwise – this doesn’t mean that they are unable to make decisions or that their decisions are wrong’.
42. The records show the consultant carefully considered Mrs A’s wishes and what treatment she was able to tolerate, before making the decision that she would be discharged and kept comfortable if she deteriorated, as agreed on the PEACE form.
43. The consultant decided to stop the antibiotics. Our adviser told us there are a range of decisions that the Trust could have made here, and this one falls in line with Good Medical Practice 16 which says:
‘In providing clinical care you must: a. prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs b. provide effective treatments based on the best available evidence c. take all possible steps to alleviate pain and distress whether or not a cure may be possible d. consult colleagues where appropriate f. check that the care or treatment you provide for each patient is compatible with any other treatments the patient is receiving, including (where possible) self-prescribed over-the-counter medications’.
44. There were also a range of possible treatment plans on discharge. As Mrs A was not compliant with medication and often refused to take it, the chosen plan to treat her conservatively and keep her comfortable was in line with the above guidance, and also in line with the NICE guidance NG15. This says, ‘When deciding whether or not to prescribe an antimicrobial, take into account the risk of antimicrobial resistance for individual patients and the population as a whole’.
45. For these reasons, there are no indications of failings in the decision to discharge Mrs A without antibiotics.
46. There are no indications of failings in relation to painkilling medication on discharge. The records show the Trust put a weekly buprenorphine patch on Mrs A on 4 October 2019. The discharge summary of 8 October has a list of medication sent with Mrs A and this included the patches.
47. The nursing home records from when Mrs A was admitted on 8 October support this, as they show two available patches on the prescription chart, with the next change due on 11 October. This supports the account that the Trust sent the patches with Mrs A on discharge and there was one in place when she arrived.
48. We accept Mrs U tells us that her mother was not wearing it when she was admitted at the nursing home. We cannot explain this discrepancy, and it would not be right for us to speculate about what happened to the patch.
49. The medical records show in the week prior to discharge the Trust controlled Mrs A’s pain in hospital with a combination of the patch and paracetamol, to be taken when needed. This was the medication written on the discharge summary and so it was reasonable to conclude this would be sufficient. At the point of discharge the medication the Trust gave Mrs A was in line with the GMC guidance which says, ‘take all possible steps to alleviate pain and distress whether or not a cure may be possible’. For this reason, there are no indications of failings in relation to pain relief on discharge.
The Trust included incorrect dates in the complaint response.
50. The Trust’s initial complaint response gave the incorrect date that Mrs A was admitted to hospital. We recognise this must have been upsetting for Mrs U and made her doubt the accuracy of the complaint response.
51. The Trust acknowledged this mistake in its next response and gave an apology. This was in line with Our principles of good complaint handling which say, ‘Public bodies should promptly identify and acknowledge maladministration and poor service, and apologise for them’. We think the Trust took sufficient action to remedy the mistake and there is nothing further we could ask it to do.
52. We hope the explanation of our decision provides reassurance that the care and treatment the Trust gave Mrs A was in line with guidance. Where there were indications of failings, we think the Trust has taken sufficient action to put things right. We can see the Trust took Mrs U’s concerns seriously and has made improvements because of this.
53. We know this experience has been painful for Mrs U and her family and we are grateful to her for taking the time to share the information to help improve services.