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Kent Community Health NHS Foundation Trust

P-002595 · Statement · Decision date: 15 May 2024 · View Kent Community Health NHS Foundation Trust scorecard
Treatment Care plan failures
Complaint (AI summary)
Mrs W complained the Trust provided inadequate wound care and failed to act on infection concerns, leading to hospitalisation, cranioplasty removal, and a stroke.
Outcome (AI summary)
The ombudsman found no indication that the Trust failed to act in line with standards and guidance regarding Mrs W's wound care, thus taking no further action.

Full decision details

The Complaint

3. Mrs W complains about the wound care she received from the Trust between September 2020 and February 2021. She says the Trust did not provide adequate care to the wound and failed to act when it was not healing. She says the tissue viability nurse only assessed her wound in person once, with the other assessments being done through pictures. She says she voiced her concern her wound was infected and the Trust missed opportunities to address this.

4. Mrs W explains the impact of this is:

• she was hospitalised and spent around 8 weeks in hospital recovering • due to the severe untreated infection, she has had the cranioplasty removed and it cannot be replaced due to the high risk. She is missing a piece of her skull she has to wear head protection whenever she leaves the house for the rest of her life • she had a stroke when the cranioplasty was removed which she thinks could have been avoided. This has affected her speech, and she is partially paralysed on her left side • she has been caused significant distress and upset.

5. To resolve her complaint, Mrs W would like the Trust to accept the care could have been better and apologise to her. She would like service improvements to be put in place to stop this from happening to anyone else in the future.

Background

6. Mrs W, who suffers with epilepsy, underwent a cranioplasty procedure (a surgical repair of bone in the skull) in 2019. She was concerned with the way the wound on the top of her head was healing.

7. As the wound was not healing fully, Mrs W was referred to the wound clinic at the Trust in September 2020, which she attended roughly twice per week.

8. On 6 February 2021 Mrs W suffered a severe seizure and was taken to hospital. At the hospital she underwent surgery to remove the cranioplasty. Mrs W suffered a stroke after her admission to hospital.

Findings

13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any indications that something has gone wrong.

14. NMC guidance says nurses should use up-to-date knowledge and evidence to assess and deliver care and make patient-focused, evidence-based decisions. It says nurses must recognise the complexity of a case and when specialist knowledge and expertise is necessary.

15. The Trust’s antimicrobial dressings guidance says to follow Pathway 2 for patients who do not present with an infection but are at high risk. Pathway 2 says an antimicrobial dressing could be considered with the input of a Tissue Viability Nurse (TVN – a nurse specialising in complex, non-healing wounds). It says to use appropriate solution to cleanse the wound.

16. Mrs W complains that her wound was not managed correctly by the Trust. She thinks the nurses should have escalated when the wound was not healing after several months. She says she told the nurses she was concerned the wound was infected as it was not healing but they did not take any action. She says she only saw the TVN in person once, and other times they just reviewed photographs.

17. The Trust says its nurses regularly assessed and dressed Mrs W’s wound and asked for specialist input from its TVN as necessary. It says it confirmed there was no infection with a swab on her first appointment and monitored her for signs throughout. It says it appropriately asked Mrs W to speak with her specialist consultant when she had concerns about the failure to heal.

18. Between September 2021 and February 2022, Mrs W was seen by the Trust more than 40 times, roughly every three days. We can see one of the same three nurses saw Mrs W at each appointment. Our adviser explained both the frequency of visits, and seeing the same nurses would have meant Mrs W experienced consistency in care and the Trust would have had the best possible opportunity to monitor any concerning changes.

19. On 23 September we can see the wound was described as dry and we can see at most subsequent appointments the notes show the nurses washed and moistened the wound. We can see nurses regularly applied creams and used octenilin (a wound irrigation solution used to clean and moisten chronic skin wounds).

20. Our adviser confirmed it was appropriate to introduce moisture to the wound with octenilin. Their opinion is supported by NICE guidance (ESMPB2) which says a moist environment is important in promoting healing. This use of moisturising solution is supported by Pathway 2 of the Trust’s policy. Overall, it appears the nurses assessed Mrs W and delivered patient-focussed care in line with NMC guidance.

21. The nurses escalated to the TVN on 30 September, who saw Mrs W and instructed the use of medical honey (a natural antimicrobial) in an antimicrobial dressing. These dressings were used throughout Mrs W’s time at the Trust. Our adviser explained these dressings are used to promote an ideal environment for healing and prevent infection causing bacteria from growing. They therefore felt the TVN involvement, and actions they recommended were appropriate, and in line with the Trust’s policy on antimicrobial dressings (Pathway 2).

22. The records show the TVN was consulted at other times throughout the period of care for example around 8 October and 12 November. Our adviser was pleased to see this as they explained the TVN would give the nurses expert advice on what to do and confirm their actions were having the desired effect.

23. This appears to show the nurses assessed Mrs W and recognised this was a complex wound and escalated for specialist advice in line with NMC guidance. We can also see the Trust recommended Mrs W spoke with her consultant in December 2021, when there was concern over the wound not healing. We can also see the Trust shared its records with Mrs W’s GP. Our adviser felt this escalation was in line with NMC guidance.

24. We understand Mrs W’s concerns that, other than on the first occasion, the TVN did not see her face to face. We know this led her to believe the TVN was not able to properly consider her wound and give the nurses the best advice on what to do.

25. Our adviser told us that while Mrs W was seen in the clinic, wound management is often done in the community through home visits. They explained it is therefore rare for a TVN to be present at an appointment and is a common practice for them to review pictures and information sent through by nurses.

26. We can see the nurses regularly took photographs of the wound and took measurements to document how it was healing. Our adviser did not have any concerns with the way the TVN reviewed the information in this case and felt the advice they gave was what would be expected based on the wound. It seems to us that the TVN being unable to see Mrs W face-to-face would not have prevented them from properly assessing her.

27. We understand Mrs W was concerned about infection throughout her time visiting the Trust. The Trust took a swab upon Mrs W’s first appointment at the suggestion of her consultant. The records of 25 September show Mrs W told nurses she had confirmation from the microbiology lab there was no infection present from the swab.

28. We can then see the nurses regularly recorded there were no visible signs of infection indicating they were checking and assessing her for this. Our adviser reviewed the records and pictures and did not think there was any indication of a chronic infection at this time.

29. Our adviser explained that the scalp can be a difficult area to heal, as the skin is very tight in this area. Furthermore, he explained Mrs W had diabetes which can negatively affect a person’s ability to heal. This tells us there was the possibility Mrs W’s recovery would be complex.

30. We can see Mrs W spoke with her consultant in December 2020. She was told further surgery was needed to debride the wound (where dead tissue is cut away) and shave down the prosthesis under the skin to help the wound heal.

31. Considering the evidence, including our adviser’s opinion, there appears to be a number of reasons for Mrs W’s wound not healing. We do not think it was an indication that the nurses missed signs of a chronic infection.

32. In summary, we think the Trust assessed, treated, and escalated Mrs W in line with relevant NHS guidance and standards. We do not think the evidence suggests that the Trust missed signs of an infection. As we have not seen any indications of maladministration, we will take no further action on this complaint.

33. We do not wish to diminish the obvious impact Mrs W has experienced since the events she complained about. We know she has experienced significant health problems and were very sorry to learn about how she has been affected.

Our Decision

1. We have carefully considered Mrs W’s complaint about Kent Community Health NHS Foundation Trust (the Trust). We were very sorry to learn of the health problems faced by Mrs W over the past few years. We know they have impacted her significantly.

2. Having looked into Mrs W’s complaint, we have not seen any indication the Trust failed to act in line with standards and guidance. We will therefore not take further action. We appreciate this might be disappointing for Mrs W, but we hope this statement clearly explains what we have considered and our reasoning.

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