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.