Injury during dialysis appointment
22. Ms B is concerned about the injury her aunt sustained during a regular dialysis appointment.
23. On 3 January 2022, Miss H attended Tottenham Hale Renal Dialysis Unit for her regular dialysis appointment. Dialysis is a treatment for kidney disease which is used to filter blood and manage the disease.
24. Miss H was transported by the Trust’s non-emergency transport service. The Trust provides this service in partnership with DHL, a private company funded by the Trust to transport non-emergency patients to the hospital.
25. Miss H was transported to and from the hospital by a two-person crew. The Trust’s incident report, which was written in retrospect following a complaint from Ms B, shows that before the return journey home at 19.43pm, whilst still in hospital, Miss H sustained a wound with broken skin to her right shin when the handle of a wheelchair knocked her leg whilst she was being moved into it from a bed.
26. The serious incident report says the wound was dressed with a plaster and Miss H was taken home.
27. We have looked at the Trust’s incident report and asked it for CCTV or camera images of the incident to consider whether correct handling methods were used or whether we think the injury could have been avoided. Unfortunately, the Trust’s CCTV system overwrites after 30 days and therefore we cannot look at this.
28. We have also considered whether we can question staff in more detail about the detail of how the incident occurred, however, staff are unable to recollect this information due to the time that has passed. In addition, we have noted no other third party witnessed the incident.
29. We know the incident and events following it are distressing for Ms B. We have thought about whether the incident was avoidable but due to a lack of evidence, we are unable to say for certain whether the incident which caused the wound could have been avoided and therefore can only comment further on the events that happened afterwards, which we have done below.
30. The Trust did log the broken wheelchair for fixing. However, the incident was not logged or reported as serious at the time of the incident and a serious incident report was only carried out on 17 August 2022 following Ms B’s complaint to the Trust.
31. NHS England’s guidance on serious incidents says serious incidents must be reported to identify factors that contributed to the incident.
32. The same guidance acknowledges it may be difficult to definitively say what is a serious incident, but it explains a serious incident could include an unexpected or avoidable injury that requires further treatment by a healthcare professional. This should be reported to investigate whether the incident was serious and if it could have been avoided to ensure improvements are made in the future.
33. In this case, Miss H’s wound developed into cellulitis, which is a serious bacterial infection of the skin which led to her needing further treatment in hospital. In addition, she then developed sepsis, which caused her death. However, the original incident was not reported or investigated until a complaint was made.
34. We have considered that Miss H was admitted to hospital a few days after the incident with cellulitis, caused by an infection of the wound. We think the reason for this admission should have triggered reporting of a serious incident at that time. We have therefore found the lack of investigation when Miss H was admitted, and the seriousness of her condition was realised, is a failing. We do not think the Trust could have reported the incident sooner, as it would not have known at the time of the incident what would happen next.
35. We have thought about the impact of not logging a serious incident at the earliest opportunity. The purpose of logging a serious incident is to look at whether an incident caused serious harm and enable learning for the future to prevent a similar thing happening again. A serious incident report cannot change clinical events. Therefore, we cannot link the failure to report a serious incident at the earliest opportunity to Miss H’s death as even if the Trust had logged it at the earliest opportunity, the incident had already happened.
36. We think the Trust should consider when incidents are logged and the recommendations we have made in relation to the logging of serious incidents at the earliest opportunity are at the end of our report.
Treatment of the wound
37. We have considered how the wound was treated and the impact of it.
38. We have not seen any contemporaneous records or documentation of what happened at the time of the injury. However, the Trust and Ms B have told us the wound was cleaned and a dry dressing was applied.
39. The ED records say the skin was ‘broken’ when Miss H was admitted on 5 January. Ms B has told us the wound was a ‘laceration’.
40. The RCEM guidance on soft tissue and skin injury says abrasions, which are grazes or scrapes should not require wound closure. NHS guidance on cuts and grazes says initial management of a graze would be to clean and apply a dressing.
41. NICE guidance on lacerations says initially a wound should be cleaned and dressed initially.
42. Our physician adviser told us abrasions and grazes often do not require further treatment after the graze has been cleaned and a dressing applied.
43. As the incident was not reported at the time, and we have no independent evidence to show what the wound looked like, we cannot say whether the wound was a graze or a laceration.
44. From the limited information we have about the wound at the time, we have found the Trust treated the wound in line with the relevant guidance and hope this reassures Ms B.
45. We have next considered how the Trust treated the injury and subsequent cellulitis when Miss H was admitted to hospital, and the impact of the injury.
46. As we have mentioned, Miss H was admitted to the Trust on 5 January 2022 after attending a regular dialysis appointment where it was found her leg had become painful and swollen.
47. When Miss H was admitted it was noted she had a cough with white sputum (mucus which could indicate infection). She also tested positive for Covid-19 and her CRP markers were raised (a marker which shows inflammation in the body).
48. Upon admission she was diagnosed with cellulitis. Miss H said she was allergic to penicillin so she was treated with intravenous teicoplanin. Both of these medications are antibiotics and are used to treat severe infections.
49. The following morning, Miss H’s medical history was explored in more detail and it was agreed her previous experience with penicillin, which had caused sickness, was more likely than not an adverse effect of it, rather than an allergy. At this stage, Miss H’s antibiotics were changed to flucloxacillin (an antibiotic which is part of the penicillin group of medication).
50. On the same day, Miss H was found to have gram-negative rods (a group of bacteria which can cause a range of serious infections). At this stage Miss H’s antibiotics were changed to tazobactam, used to treat a broad range of infections. The plan was to consider adding gentamicin (a broad spectrum antibiotic used to treat sepsis) if she showed signs of sepsis.
51. Later on 6 January, the microbiology department confirmed the gram-negative bacteria rods were specifically enterobacter cloacae, which is a bacterial infection. At this stage, the antibiotics were changed to ertapenem which can be used to treat skin infections.
52. On 7 January Miss H’s blood pressure started to fall and she was becoming more unwell. At this stage, gentamicin was also added to Miss H’s medications.
53. On 8 January, Miss H deteriorated further and sepsis was suspected so staff gave her intravenous human albumin solution (HAS). This was used to prevent further renal dysfunction in light of Miss H’s already poor kidney condition.
54. Our physician adviser explained the medication used for the treatment of Miss H’s symptoms at this stage was in line with BNF guidance which says teicoplanin can be used intravenously to treat cellulitis.
55. We have seen BNF guidance which says ertapenem is licensed for use of infections of the skin. In addition, NICE guidance on cellulitis says flucloxacillin is the first-choice antibiotic for treatment of cellulitis.
56. NICE guidance on sepsis says broad spectrum antibiotics should be given and to consider HAS in patients with sepsis and shock.
57. We have found the Trust gave antibiotic treatment for the cellulitis in line with relevant guidance and changed the antibiotic type quickly to the first choice of antibiotic once staff agreed it was safe to prescribe to Miss H.
58. We found the Trust acted in line with relevant guidance to change its treatment plans when Miss H was deteriorating.
59. Our physician adviser noted Miss H’s several serious comorbidities, some of which, including her regular dialysis treatment and diabetes would have compromised her immunity. In this case Miss H developed cellulitis because of the injury on her leg, which caused sepsis. Our adviser explained aggressive treatment was given and we have seen it was in line with the relevant guidance.
60. We know the chain of events after the abrasion was very serious and distressing for Miss H’s family. However, we cannot criticise the Trust for the unfortunate events that took place after the incident. This is because we cannot say the Trust could have known what would have happened following the abrasion and we found it was treated at the time in line with guidance. We also found Miss H was treated in line with relevant guidance when she was admitted to the Trust after she developed cellulitis.
61. We hope we can provide reassurance to Ms B that her aunt received appropriate care following the incident which caused the abrasion.
Pain management
62. Ms B says her aunt’s pain was not monitored or managed during her admission to the Trust, which caused pain and distress.
63. We have looked at the records and can see from her initial admission, Miss H had pain to her right thigh. This is where the abrasion was and where the cellulitis had started. The records show Miss H was given analgesia in the emergency department (ED). When she was admitted to the ward, pain relief was prescribed to be taken when needed.
64. Miss H was assessed at 00.55am on 6 January and said she was not in pain. Her pain was assessed throughout that day, where Miss H said her pain level had remained the same.
65. We can see Miss H complained of pain her right leg on 7 and 8 January and she was given analgesia when needed.
66. On 9 January, Miss H screamed in pain when she was moved. Staff offered analgesia, but the records show Miss H refused this. Following this, Miss H started to complain of chest pain. At this stage anticipatory medication, which is given to alleviate symptoms of pain and discomfort was prescribed.
67. We can see throughout the records Miss H’s pain was assessed and monitored daily and she was offered analgesia throughout her admission.
68. On 11 January Ms B told us her aunt was not given any pain relief on 11 January whilst she sat with her all day. The records show Miss H was given oxycodone at 14.23, which is a strong pain relief containing opioids. After this, she was referred to the palliative care team, and her pain continued to be monitored daily.
69. The NMC code says symptoms of pain should be recorded and responded to by the clinical team. It also says timely referrals to another practitioner should be made when any action, care or treatment is required.
70. We have considered Ms B’s information that she did not see any pain relief given to her aunt and she says she was in pain, specifically on 11 January. However, the records show Miss H’s pain was managed in line with guidance and that her pain levels were recorded and responded to.
71. We have seen the wider clinical team were involved in managing and assessing her pain. We understand there are conflicting views on what happened in relation to pain relief, however, we have considered pain is subjective and individual to the person. Pain relief will wear off at different times in different people. We hope to provide reassurance to Ms B that the records show her aunt’s pain was managed, however, we have not seen evidence that means we can say there was a failing in this area.
Nutrition and fluid management
72. Ms B says her aunt’s food and fluid intake was not assessed and this made her more unwell.
73. The records show that when Miss H was admitted, she was nil by mouth, which is a medical instruction to withhold food and fluids. The records show this was a clinical decision in case she needed emergency surgery.
74. The nil by mouth decision was reviewed on 6 January and it remained in place. On 7 January it was decided Miss H would not be having any surgery and therefore, the nil by mouth instruction was lifted.
75. During the time Miss H was nil by mouth, we can see IV fluids were given. This was done under strict medical advice because of concerns about fluid overload.
76. When the nil by mouth instruction was lifted, we can see food charts which monitored her food intake. We can see Miss H received assistance at mealtimes on 8 and 9 January. However, on 10 and 11 January it was noted Miss H was too drowsy to eat and drink and was largely unresponsive. At this stage, Miss H was referred to the palliative care team and a nil by mouth instruction was put in place from 11 January.
77. We have also seen fluid balance charts which show Miss H’s fluid intake was monitored throughout her admission, when she was not nil by mouth.
78. Our nurse adviser explained Miss H was very unwell from admission and had complex needs. Our nurse adviser looked at the fluid and nutrition charted and explained IV fluids were administered under strict guidance and Miss H’s food charts were completed. They also explained Miss H was referred to the palliative care team for further advice and support once she stopped eating.
79. NICE guidance on nutrition says nutrition support should be considered for people who have eaten little or nothing for more than five days.
80. NMC standards for nurses guidance says nurses should keep complete, clear and accurate records and they should also observe, assess and optimise nutrition and hydration status and determine the need for intervention support.
81. We have seen clear documentation to show Miss H’s food intake was monitored when she was not nil by mouth. We have also seen records to show her fluid intake was monitored throughout her admission. We have also seen she was given support and assistance at mealtimes when she was able to eat and drink.
82. We know it will have been distressing for Ms B to see her aunt unable to eat and drink, but we hope we can provide clarity for Ms B.
Pressure sore management and hygiene
83. Ms B says the Trust did not manage her aunt’s pressure sores, which left her in an unhygienic condition.
84. When Miss H was admitted the Trust assessed her risk of pressure sores using the Waterlow assessment tool. This is a tool to help calculate the risk of someone developing pressure sores. The assessment showed Miss H was at very high risk of pressure sores.
85. We can see Miss H was turned every 2-3 hours and her pressure sore risk areas were assessed between 5 and 11 January. During this period, it is noted Miss H’s skin remained intact.
86. During the same time, Ms B told us she moved her aunt herself and asked several times for help in doing this.
87. Between 11 and 13 January there are no references to specific pressure sores being checked because she did not have any. Our nurse adviser explained Miss H’s skin in general was assessed every day until 13 January and risk assessments were completed between 11 and 13 January. During this period, it was noted her skin was oedematous, which means it was swollen. Our nurse adviser said there was in depth monitoring of Miss H’s skin checks and comfort and it is unlikely she developed a pressure sore during these two dates.
88. We can also see after 11 January repositioning continued and Miss H’s comfort was checked hourly. Miss H reported she remained comfortable.
89. NICE guidance on pressure ulcers says an assessment of pressure ulcer risk should be carried out for adults being admitted to secondary care. It also says a validated scale, such as the Waterlow score should be used.
90. The same guidance says skin assessments should be offered to adults who have been assessed at being of high risk of developing pressure ulcers.
91. The guidance says adults who have been assessed as at high risk should be moved every four hours either by themselves or with help.
92. We have seen Miss H was assessed upon admission in line with the relevant guidance. She was continually assessed and monitored, and general skin assessments were carried out. We can also see Miss H was repositioned more frequently than the guidance says.
93. We recognise Ms B was clearly concerned about her aunt’s pressure sore management and have seen messages to family members at the time which express her concerns. We have now seen information which is different to the contemporaneous records and therefore, after considering both, we do not have enough information to say there was a failing in how the Trust managed the risk of pressure sores.