Care of Mr C’s foot after surgery in January 2018
24. Mr T is concerned about the care his father received after the original surgery took place in January to repair his broken right foot. He says the care was poor and eventually led to the wound becoming infected.
25. A metal plate was put into Mr C’s right foot in January 2018 during surgery after he broke his foot. The plate collapsed in February 2018 and treatment options were considered.
26. Mr C was seen as an outpatient in orthopaedic clinics in May, July and October 2018. The clinic letters show at each appointment clinicians had concerns about the loosening metal in his right foot.
27. In the May and July appointments, concerns were also noted about charcot arthropathy (a serious condition where the bones in the feet can become weak and lead to dislocations and loss of feeling). If this condition is not treated quickly, changes to the shape of the foot and ankle can happen and ulcers and sores can develop. Charcot arthropathy usually develops in people with diabetes who have then had a broken bone in their ankle or foot.
28. The records from the appointments in May and July 2018 show the plan was to keep Mr C’s right foot in a total contact cast (a fiberglass or plaster shell with a bar on the bottom which fits around a patient’s foot and leg closely) for eight weeks after each appointment.
29. NICE guidance on diabetic foot problems says clinicians should be aware that if a person with diabetes breaks their foot or ankle, charcot arthropathy may develop. It says charcot arthropathy should be suspected where there is redness, warmth or swelling.
30. The same guidance says a non-removable offloading device should be offered when charcot arthropathy is suspected.
31. BOAST guidance says close contact casts are an option for patients over 60 if reduction in movement can be maintained.
32. Our orthopaedic adviser said total contact casting was used as a non-removable offloading device and this was reasonable to use when clinicians noted a higher temperature around the ankle, which could show the start of charcot arthropathy.
33. When Mr C was seen in the outpatient orthopaedic clinic in October 2018, the previous CT scans and X-rays were considered and doctors decided to operate on Mr C’s right foot because of the ongoing pain and difficulty in moving it.
34. Our orthopaedic adviser explained Mr C’s broken bone could not be reasonably controlled. They said surgery was an acceptable treatment plan after discussion with Mr C and colleagues when non-operative management (total contact casting) was not helping the broken bone heal.
35. Mr C was booked for surgery in March 2019. The records show a discussion between the surgeon and anaesthetist took place on the day and it was decided that surgery was too risky because of Mr C’s ongoing breathlessness. The decision was to delay the surgery on Mr C’s right foot until further assessment of the ongoing breathlessness had taken place and it had been resolved.
36. RCS guidance says surgeons should listen to and respect the views of other members of the team involved in the patient’s care and respond to any concerns they may have.
37. Our orthopaedic adviser explained the surgery in March was elective (surgery which is planned ahead) and any risks should be discussed and potential reversible problems, such as breathlessness, should be resolved before surgery. Our orthopaedic adviser also noted that the risks of carrying out surgery at this stage, where Mr C was already unwell and had several other health issues would have been significant and would have potentially outweighed the benefits of surgery.
38. We have seen evidence the risks of the elective surgery were discussed in line with RCS guidance and discussed with Mr C.
39. The records show the Trust had discussions with Mr C about ongoing treatment when the metal plate collapsed. We have also seen the Trust treated Mr C’s broken bone in line with the relevant guidance, taking into consideration his diabetes and the possibility of him developing charcot arthropathy.
40. We do not find failings with the care Mr C received after his initial surgery in January 2018, and we hope to reassure Mr T that his father’s care plan was appropriate and in line with guidance.
Wound care in hospital during November and December 2019
41. Mr T is concerned that during his father’s stay in hospital, his foot wound was not cared for properly and this caused an ulcer and the infection to become worse.
42. Mr C was admitted to the Trust in November 2018 after having increased breathlessness and having a hypoglycaemic episode (a complication in people with diabetes where their blood sugar levels drop to dangerously low levels). He also had a large wound in his right foot where the metal plate had collapsed.
43. The medical notes also show chronic oedema (a condition where extra fluid in the body can cause swelling, which can be caused by infection and other things) in Mr C’s right calf.
44. In November 2019, Mr C was seen by a podiatrist (a specialist in feet and ankles), who noted an ulcer on his right heel. Significant blood loss was also noted. A swab of the wound was taken, it was dressed, and the podiatrist recommended antibiotics and asked for an opinion from an orthopaedic specialist.
45. NICE guidance on pressure ulcers says that people admitted to hospital should have a pressure ulcer risk assessment within six hours of admission. It also says that people at high risk of developing pressure ulcers should have a skin assessment and advice should be given on repositioning.
46. The same guidance says the care plan should note the results of a skin assessment, the need for additional pressure relief and take into account how well a patient can move and reposition themselves, as well as other health issues. Plans to reduce heel pressure should also be considered.
47. Our nurse adviser told us that Mr C was at high risk of developing pressure ulcers because of his health issues, and could not move around easily because of the ulcer and obesity.
48. We have not seen any evidence that a risk assessment was carried out and we have not seen a repositioning chart. We consider this a failing.
49. NICE guidance says the surface area of pressure ulcers should be recorded, if possible using photographs. It also says an assessment should be done to consider a patient’s risk factors. A skin assessment should also take place.
50. We see some reference to the ulcer in the notes. But we have not seen any detailed assessment of the ulcer, and the notes do not describe the wound or size of the ulcer. This lack of recorded assessment is more evidence of a failing.
51. We have not seen an individualised care plan for managing the ulcer in Mr C’s right foot. We have seen a body map and skin integrity pathway and a completed SSKIN record (a resource used to help assess and manage pressure ulcers). But none of these documents show a thorough assessment of the ulcer and some parts are incomplete. We consider this evidence of another failing.
52. Where we see evidence of failings, we look to see if they can be linked to the claimed impact.
53. Mr T told us the ulcer was infected and this caused his father to develop sepsis.
54. An adult infection and sepsis screening tool was completed when Mr C was admitted in November 2019. Our nurse adviser looked at this and told us the screening tool showed a respiratory tract infection (an infection in parts of the body involved with breathing, such as airways or lungs).
55. We have looked at the records and we have not seen evidence that Mr C got sepsis during this hospital stay. Mr C did have antibiotics throughout his stay, but the records do not show that he developed sepsis.
56. We have found the failure to holistically assess Mr C (treat the whole person) and manage the ulcer in line with guidance, meant his foot wound got worse and developed the ulcer. Opportunities to help manage pain and prevent the foot wound and ulcer getting worse were missed.
57. We need to consider the actions taken by the organisation to put this right. In this case, the Trust has not acknowledged the failings we have seen, so no action has been taken. We explain the recommendations we are making at the end of this report.
58. We hope our recommendations reassure Mr T that changes will be made to improve services in the future.
Oxycodone injection
59. Mr T says his father was wrongly given a dose of oxycodone in December 2019, shortly before he died.
60. The records show that in December 2019, Mr C’s condition deteriorated significantly. His renal (kidney) function was worsening, and his overall condition was getting worse.
61. Mr C had been seen by the palliative care team from early December onwards and he was given 2.5 milligrams of oxycodone to relieve pain. The notes show Mr C was given oxycodone on several occasions after this.
62. NICE guidance on palliative care says strong painkillers can be prescribed to treat pain and information should be given to patients and their carers about the medication.
63. NICE guidance says that breathlessness in the end stages of life can be managed with strong painkillers.
64. Our nurse adviser explained that when someone is nearing the end of their life they may show signs of distress and agitation.
65. We have considered how quickly the last dose of oxycodone would have taken effect. The handbook of acute pain management says that studies show it takes around 30 to 60 minutes for oxycodone given orally and by injection to take effect. So it is unlikely the last dose of the medicine would have been in Mr C’s system when he died a few minutes after the injection.
66. The records show that Mr C was given this dose by an injection because he was unable to take medication by mouth. Our nurse adviser told us when someone becomes drowsy and unable to take medication, it is appropriate to consider giving the medication in a different form, such as with an injection to make the patient gets the medication.
67. We have found it was appropriate to give oxycodone to manage Mr C’s pain and breathlessness as he approached the end of his life and there is no evidence of failings in this part of the complaint.
68. We hope that the report can give some reassurance to Mr T that the medication was appropriate and used in line with guidance to ease his ongoing symptoms and did not speed up his father’s death.
Cancer diagnosis
69. Mr T says his father was never given confirmation of his cancer diagnosis and that his treatment options were not discussed properly. He says this left his father and the family with uncertainty about his condition.
70. Mr C had a CT scan (a computerised tomography scan gets detailed images of inside the body) in May 2019. The scan showed a nodule on his lung (a small lump which can sometimes be cancerous). The Trust wrote to Mr C later that month to explain it was unsure whether this was cancer at this stage. Nodules can also be caused by other things such as infection or scarring.
71. The Trust sent Mr C for a PET scan (a positron emission tomography scan uses a radiotracer to see how well parts of the body are working and can help in diagnosing cancer). This scan was done in July 2019.
72. The results were discussed in a clinic later that month and he was told the nodule was likely to be cancerous. The Trust wrote to Mr C and his GP after this appointment to confirm this.
73. In August 2019, Mr C was seen in clinic again and he was told the nodule was cancerous and treatment was discussed. The records show a letter was sent in early September to Mr C and his GP to confirm this diagnosis.
74. Another letter was sent to Mr C and his GP after a clinic appointment in September, where his lung cancer diagnosis was discussed again.
75. GMC guidance says doctors must give patients information they want or need to know in a way they understand. It also says doctors should work in partnership with patients and discuss their condition, its progression and risks and uncertainties.
76. We have found that Mr C was kept informed of his condition and treatment options. We can see he attended several clinics in 2019 and the Trust wrote to him after each clinic appointment to keep him informed. We have not seen evidence that Mr C was left unsure about his diagnosis of lung cancer.
77. The records show various options for treatment of the lung cancer were considered, including surgery and stereotactic ablative radiotherapy (SABR is a type of radiotherapy used to treat cancer). It was decided treatment would be unsuitable because of Mr C’s performance status (PS). PS is a score given to a patient’s ability to function in daily life and activities. It is an important factor in deciding on what treatment is best for patients with cancer. The score ranges from zero to four, with zero being fully functional. The Trust also took into consideration his other health issues and a supportive care approach was taken.
78. The records show that at the time of the lung cancer diagnosis Mr C had a PS rating of three. He also had other health issues which included kidney failure, lung fibrosis (a condition where the lungs become thicker and scarred), breathlessness, obesity and diabetes which contributed to his overall health.
79. NICE guidance on lung cancer management says an oncologist should decide if a patient is suitable for radiotherapy, considering their PS and other health issues.
80. Our oncologist adviser explained that a high dose of radiation, which would be used with SABR treatment, could have caused further breathlessness and lung fibrosis, which Mr C already had.
81. There are three types of active treatment for early stage lung cancer. These are surgery, chemotherapy and radiotherapy (SABR). Our oncologist adviser explained that for a patient to cope with any of these treatments, they would need a PS score of zero or one.
82. We have found the Trust considered treatment options, but there were no active treatment options suitable for Mr C’s lung cancer. We hope this report can reassure Mr T that options were considered and discussed with his father.