14. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done this, we cannot link the events complained about with the negative impact Mr Y has claimed.
15. Mr Y says the Trust assessed H on admission and the family were told not to worry about her eye and to continue to monitor it. He says the family were given Nurofen (ibuprofen) to treat H’s temperature.
16. On 15 May, H was weak and drowsy. Mr Y says she had more pox, heavy breathing and a high temperature. After a call to 111, H was taken to hospital where she stayed for two days and was put on an antibiotic drip to treat a serious skin infection. We appreciate this was a worrying time for Mr Y as he felt the Trust had made an error in prescribing ibuprofen.
17. Mr Y says the hospital staff told the family ibuprofen should not be given to any child with chicken pox, due to the dangers this can cause with infection.
18. Mr Y says H’s scarring is a direct result of the prescribed ibuprofen.
19. The Trust said H was seen by a junior doctor who noted the possibility of chicken pox affecting the eye and the ophthalmology (eye) team were consulted. The Trust advised she could be discharged but, should matters not settle she should return for an ophthalmology review. The Trust confirmed H was discharged with ibuprofen.
20. The Trust explained as a precautionary measure many authorities suggest that ibuprofen is avoided as there is a link between patients who have chicken pox developing skin or soft tissue infection after taking this medication.
21. The Trust goes on to say it cannot be said for certain that ibuprofen should never be given to any child with chicken pox, because the reported link has not been fully confirmed. It accepted that paracetamol would have been better in this instance.
22. The Trust said patients with chicken pox will always have the risk of having complications and it can never say with certainty that any drug, in this case ibuprofen, was ‘causative of any such extension of chicken pox related complications.’
23. The Trust reflected on the complaint and said a reminder had been sent to all medical and nursing staff about this issue.
24. The medical records show a triage nurse assessed H on arrival. The ‘emergency department (ED) Paediatric Assessment’ states H: • had reduced eating but was tolerating fluids • had last been given Calpol (paracetamol) at midday • had passed urine as normal but her bowels were not open • was warm and well with no distress.
25. In the same document the nurse observed that when H was in triage she had a fever and while quiet and clingy to mum, she was alert and active, fully mobile and smiling.
26. The assessment said Nurofen (ibuprofen) was ‘prescribed and given and the plan was for her to be returned to waiting room for doctor to see.’
27. H was then seen by an ED doctor who discussed her symptoms with ophthalmology and advised it was likely ‘conjunctivitis associated with chicken pox which is very common.’
28. The Trust discharged H with the advice that she did not need treatment and to return if her eye(s) worsened.
29. Our adviser explained that ibuprofen should not be given where chickenpox is suspected without being advised by a doctor. This is explained on the NHS website. But, there are no national guidelines about the prescription of ibuprofen in cases of chickenpox. It is generally not good practice for healthcare professionals to prescribe ibuprofen for chickenpox.
30. The NICE chickenpox guidance says avoid NSAIDs (nonsteroidal anti-inflammatory drugs) like ibuprofen. This is based on concerns that use of NSAIDs in chickenpox may be associated with an increased risk of severe skin and soft tissue infections.
31. Our adviser noted there are studies that investigate the link of increased risk of secondary infection when ibuprofen is used in cases of child chickenpox, but the findings vary.
32. Our adviser explained in exceptional cases ibuprofen should be prescribed by a doctor and the risks and benefits discussed with parents. Exceptional cases are where the symptom of pain and fever is more than the possible increased risk of secondary infection.
33. In exceptional cases prescribing ibuprofen can help reduce symptoms of pain and fever in child chickenpox. Our adviser said using ibuprofen for chickenpox can increase the risk of soft tissue infections and if prescribed, it should be documented clearly in the medical records that the risk has been reviewed in line with relevant standards.
34. As a triage nurse prescribed the ibuprofen, NMC standards apply. The NMC Code says a nurse should:
• act in the best interests of people at all times and get properly informed consent and note it before carrying out any action • keep clear and accurate records and carry out documented risk assessments.
35. The NMC Code says when prescribing a nurse should:
• advise on, prescribe, supply, dispense or give medicines within their limits of training and competence • prescribe, advise on, or provide medicines or treatment if they have enough knowledge of that person’s health and are satisfied that the medicines or treatment serve that person’s health needs • make sure that the care or treatment they advise on, prescribe, supply, dispense or give is compatible with any other care or treatment they are having, including (where possible) over the counter medicines.
36. Our adviser pointed out there is no record of a documented discussion of the risks of ibuprofen. But, they did note it is possible a discussion with the parents may have happened but was not documented.
37. We spoke with Mr Y about the family’s experience at the Trust on 14 May 2022. We appreciate there has been some time since these events and this may affect what he remembers.
38. Mr Y says as the family were leaving the hospital, a nurse came with ibuprofen and explained it would help H’s temperature. He said he cannot remember if they were advised to return if her symptoms got worse and cannot recall any other information being given by the nurse but he does not think they said anything else. He says H was given one dose of ibuprofen by family in the car journey on the way home.
39. The medical records show a triage nurse prescribed ibuprofen. The Trust’s final response says ophthalmology were consulted about the care and treatment of H, which is not noted in the medical records. Our adviser explained it is good practice for these discussions to be recorded in the medical records.
40. It seems the medical notes are incomplete. On balance, we have decided the Trust did not have a conversation with the family about the associated risks of ibuprofen use and monitoring H’s symptoms after the dose of ibuprofen.
41. The Trust not discussing the risks with the family is a sign of failing.
42. We have noted above how Mr Y says H was affected by the ibuprofen.
43. Our adviser explained it is difficult to say how likely it is that H had an allergic reaction or increased risk of skin infection because of the ibuprofen, because she was given a one-off single dose.
44. Our adviser said based on odds ratios, it is likely H’s risk of secondary infection is on the bottom of the risk exposure threshold. An odds ratio is a commonly used tool to report the chances of something happening. The larger the odds ratio, the more likely the event is.
45. Our adviser explained that annually chickenpox in children under five in the UK is approximately 13,000 out of 100,000 children and the risk of secondary infection from chickenpox in children under five is roughly 0.04 out of 10,000 children each year.
46. Our adviser explained if ibuprofen has an odds ratio of five for secondary infection in chickenpox, this means the risk goes from 0.04 in 10,000 to 0.2 in 10,000. This means any increased risk of secondary infection for H would have been small.
47. In summary, it would be hard to directly link the scarring to the medication as chickenpox on its own can cause scarring even without the use of ibuprofen. We appreciate the scarring is distressing for H’s parents.
48. We have considered the pain and distress Mr Y reports H experiencing because of the failing. He says this resulted in himself and his wife experiencing stress for the two days H was in hospital. We are very sorry to hear about the circumstances which led Mr Y to come to us and recognise his family has been through a difficult experience.
49. With this in mind, we considered the injustice Mr Y and his family experienced by using our severity of injustice scale, a tool which allows us to make consistent and transparent recommendations for financial payments. The scale ranges from level one where we see a low-level injustice to level six, where irreversible damage, loss of life or extremes of failure in care happen.
50. Level two on the scale includes cases that have had a relatively low impact on the person affected. This will often result in a degree of distress, inconvenience or minor pain. This could also include cases where an injustice was more serious, but only took place once or was of short duration, for example a couple of weeks. This level also says we would expect the person affected to recover quickly once the poor service had ended. It says level two injustice will not usually have a significant lasting impact or any effect on the person’s ability to live a relatively normal life.
51. We believe Mr Y’s injustice falls into this level. This is because the impact Mr Y told us about is distress, anxiety and upset of short duration. We would also expect Mr Y and his family to recover quickly once the poor service had ended and we do not think the injustice had a significant lasting impact.
52. We do not think level three is appropriate because this is for cases where the injustice had a moderate impact but has lasted for a significant period of time and may impact to some extent on the affected person’s ability to live a relatively normal life. We would expect to see distress, upset or worry lasting six to 12 months.
53. We have taken into consideration the Trust’s final response. Our ‘Principles for Remedy’ say we expect organisations to accept mistakes and apologise for the impact these had. We would also expect organisations to take action to learn and improve.
54. The Trust apologised and reflected on the complaint to make sure it does not happen again. The Trust confirmed it sent a reminder to all medical and nursing staff about complications in patients with chicken pox who are exposed to drugs like ibuprofen.
55. We do not think the Trust needs to do anything more. We hope H is now fully recovered from her illness and wish her well for the future.