University Hospitals Coventry and Warwickshire NHS Trust

6. Mr P complains the Trust failed to tell any family member or carer about the ankle sores L got while in hospital between 10 and 25 January 2021. He complains the discharge notes did not mention the sores or how they were being treated. And, he complains the Trust failed to tell the relevant district nursing team of the need for L to have ongoing care for her skin damage.

7. L died in early February 2021. Mr P thinks that had district nurses seen her after her discharge, her pain and distress would have been less as the sores would have been treated. He adds that because of the failure to refer her for further treatment, the family spent L’s last days trying to keep her ankles separated and distracting her from the pain she was in, rather than enjoying her remaining time with them.

8. Mr P explains that discovering the skin damage was shocking and upsetting as it was not expected. He also says this led him to feel as though L had not been well looked after, which was upsetting.

9. Mr P would like an apology, for the Trust to accept its failings and to make sure action is taken to improve its services.

10. L was admitted to hospital on 10 January 2021 after a number of falls at home.

11. L was in her thirties at the time and had a number of health concerns including learning difficulties, epilepsy and metastatic breast cancer. Her mobility was negatively affected by her health problems.

12. During her admission, staff assessed L as being at high risk of developing pressure sores. L was nursed on a pressure relieving mattress and encouraged to change position every two hours. Staff also assessed her skin daily for signs of damage, recording any areas of concern.

13. On 23 January, staff noted that L’s inner right ankle had ‘C2’ damage. This means there was a ‘partial thickness skin loss with an intact or open blister’. This was caused by L rubbing her ankles together.

14. Staff applied a dressing to the affected area to protect it and repositioned this as needed. This was because L was not able to follow advice on separating her ankles herself.

15. The records show that L’s skin stayed in this condition on 24 January. She was discharged home the next day.

16. Mr P says the family discovered L had ankle wounds when they saw the area after she arrived home. He says staff had not told them about this.

17. L’s sister emailed the Trust to complain about this on 26 January. She included photos to show the area of skin in question.

18. The Trust considered the complaint, and a tissue viability nurse said they believed the photograph showed that L had cellulitis. The ward sister from L’s ward said L’s skin was not in that condition when she left.

19. The Trust concluded that it had not shown any failings in its actions.

23. The first thing to establish, before deciding what staff should have done in terms of telling the family about L’s ankle sores, is what condition her ankles were in when she was discharged.

24. The records show that on 24 January 2021 there was partial thickness skin loss on her ankles.

25. Staff assessed L’s skin at 7am on 25 January, but the records do not include a body map skin assessment for that date. This means there is an incomplete picture of the condition of her ankles when she was discharged later that day.

26. L’s sister gave the Trust photographic evidence of the condition of her ankles. She did this on 26 January, within 24 hours of L being discharged. Both the Trust’s tissue viability nurse and our adviser believe the photograph shows L had developed cellulitis.

27. We note the photograph only shows the condition of L’s ankles at the time this was taken. That said, we know that L had partial thickness skin loss to her ankles on 23 and 24 January. There was no full assessment of the condition of her ankles on 25 January, but by 26 January, when the pictures were taken, we know she had most likely developed cellulitis.

28. Because of the poor record-keeping on 25 January, we are not able to say with certainty how L’s ankles looked when she was discharged. Instead, we have reached a conclusion based on what most likely happened. We have decided the condition of L's ankles at the time of her discharge was almost as severe, if not as severe, as the condition recorded the next day.

Communication

29. The NMC code says nurses should give patients and their families the information they want or need to know. Given the care needed to prevent further rubbing and look after the existing sores, we consider the Trust should have told L’s family about the issues with her ankles.

30. We have not seen any evidence that shows this was done. Mr P told us the first time he and his family were aware of the damaged skin was when L came home, and they could see this for themselves. Our decision is staff did not tell them about the problems with L’s ankles and this falls so far short of the guidance in the code, that it is a failing.

Referral to district nurses

31. The Trust’s Admission and Discharge Protocol for Patients with Learning Disabilities says the hospital discharge team is responsible for arranging the discharge. This would include making referrals to community nursing where needed.

32. The discharge team is normally a multidisciplinary team (made up of difference skilled staff), but in this context it seems more likely than not that the responsibility for making an onward referral lay with the nurses.

33. The NMC code says nurses must ‘work with colleagues to preserve the safety of those receiving care’ and ‘share information to identify and reduce risk’. The code also sets out that nursing staff should do ‘a timely referral to another practitioner when any action, care or treatment is required’.

34. In this context, we consider this means the discharge team should have referred L to the district nursing team for ongoing care for her damaged skin. This would be the case even if her ankles were not as badly affected as the photographs show. Staff knew L was at high risk of skin damage and had partial thickness loss, which would need ongoing care.

35. We have seen no evidence to suggest staff made a referral. We consider this fell so far short of what should have happened to be a failing.

Impact

36. Mr P says that because of L’s ankle sores, L’s last few days of life were more painful and distressing. We decided during our primary investigation that there were no signs that staff failed to prevent the ankle sores happening. Sadly, the sores were unavoidable. Because of this, we are mindful that sadly L would have been in some degree of pain and distress even if staff had told Mr P about her ankles and referred her to district nurses.

37. Mr P explains that district nurses saw L on the evening of 25 January after the family noticed the sores and contacted them directly. He says the nurses dressed the wounds and arranged for antibiotics to be prescribed. This was done the next day.

38. Had nursing staff referred L to the district nursing team, this may have meant L was seen by them earlier. However, as the nurses saw her quickly, an earlier referral is unlikely to mean the nurses would have come much sooner. It is not possible for us to say what difference this would have made. This means we cannot reach a firm decision on whether L could have had treatment to reduce her pain and distress at home any sooner than she did.

39. We accept that it must have been incredibly distressing and a shock for Mr P and his family to have discovered L’s skin in such a poor condition when she arrived home. Had staff told him about this as they should have, this would have been minimised to some extent, as the family would have been prepared for it. As it was, L came home with serious damage to her skin which had not been present when she left the family’s care. It is easy to see how this made the family feel as though L had not been well looked after. This was an injustice to them.

40. We are also mindful that Mr P and his family had to spend time arranging for district nurses to attend to L because of the Trust’s failure to do this. This came at a time that was undoubtedly distressing and when they wanted to be spending time with L, rather than arranging care that should already have been arranged. This was an injustice to them.

1. It is clear how upsetting Mr P and his family found the effect his daughter’s, L’s, skin damage had on her during an already distressing time. It is understandable that he raised questions about what happened.

2. We have seen failings by University Hospitals Coventry & Warwickshire NHS Trust (the Trust) in not communicating the damage to those caring for L after it discharged her and in not referring her to the district nursing team.

3. We decided this did not have any serious impact on L, as fortunately, Mr P was able to get district nurses to her very quickly. We do find the Trust’s lack of communication with Mr P about this caused the family distress, worry and shock.

4. The Trust did not find any failings in its own investigation and did not take steps to put things right where possible.

5. We therefore partly uphold the complaint. We recommend that the Trust accepts the failings we identified and apologises to Mr P and his family for the impact of those failings. And, we ask the Trust to take steps to improve its service to help prevent such an issue happening again.

41. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration (fault) has led to injustice or hardship, the organisation responsible should take steps to put things right.

42. Our principles say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service. In line with this, we recommend that the Trust:

• sets out an action plan on how it intends to improve its daily skin assessment records on the ward in question, including on the day of discharge • sets out in the action plan how it will improve discharge communication with families and community care providers.

43. The action plan should be sent to us within three months of the date of the final report. It should include details of who is taking responsibility for the actions and how the Trust will achieve a positive result. The actions could include, for instance, circulating a bulletin to relevant staff members, setting up a meeting or training for staff.

44. A copy of the action plan should also be sent to the Care Quality Commission (CQC) and to Mr P.

45. The Trust should also write to Mr P and his family to accept the failings we identified and to apologise to them for the impact of those failings.

46. This should be done within one month of our final report.