Prescribing flucloxacillin
15. We have carefully considered what Mr P told us about his concerns in his complaint form and during calls and emails with our office. He told us he had previous reactions to flucloxacillin and had not taken the course his GP prescribed.
16. We discussed this case with our physician adviser. They told us NICE guidance NG141 on cellulitis is relevant. That guidance says flucloxacillin is the first choice antibiotic for cellulitis in an adult. There are alternatives if a patient has a penicillin allergy or if flucloxacillin is unsuitable.
17. When Mr P attended ED on 4 November, his ambulance and hospital paperwork stated he had no allergies. In the Trust’s Local Resolution Meeting (LRM), Mrs P, Mr P’s wife, explained she was not allowed into the room at the time. She also explained Mr P was too unwell to explain his allergy, so he directed staff to check his notes.
18. Mr P had discharge letters from his attendances in October 2019 and July 2020, in which it stated he had an allergy to flucloxacillin, causing hives and a rash. His discharge letter from May 2022 (his most recent admission), stated he had no drug allergies. Mr P’s GP had prescribed him flucloxacillin prior to this admission, but he says he had not taken it.
19. In the LRM, the urgent care consultant said that staff gave flucloxacillin as the first line treatment for cellulitis. He said that at the best of their knowledge, staff at the time would have felt that the previous reactions were not an allergic reaction. He noted Mr P never had anaphylaxis (a life-threatening reaction) to flucloxacillin.
20. Our physician adviser noted the uncertainty regarding Mr P’s allergy. They commented that a documented reaction of hives should be considered an allergic reaction, even though it was not life-threatening.
21. We reviewed the records from Mr P’s attendance in May 2022 and note staff addressed the query of his allergy on 15 May 2022. The IT system had stated Mr P had an allergy to flucloxacillin, so staff were alerted. The notes indicate Mr P confirmed he had no allergies and this was checked with his GP records. He was monitored for a reaction and none occurred. His wound swab grew a bug that was sensitive to flucloxacillin and he was treated successfully with it.
22. Our physician adviser confirmed that as Mr P had been previously successfully treated with flucloxacillin, with no adverse reaction, it was reasonable for this to be initiated in November, with careful monitoring.
23. We have considered all the evidence and find the Trust acted in line with the relevant NICE guidance. This is because the Trust considered a possible allergy and then provided the first choice antibiotic for Mr P’s condition because there was no strong evidence of an allergy.
24. We find no failings in the prescribing and administration of flucloxacillin.
Nursing management of wounds
25. Mr P was admitted with cellulitis of his legs. He had longstanding leg ulcers which the district nurses dressed for him twice a week. On 6 November, he developed a widespread rash and blisters. He complains that nursing staff on the ward did not attend to his wounds and dressings.
26. We have looked at the two different issues Mr P had with wounds, the ulcers he had before admission and the blisters that developed. We have set out our consideration separately here to make our explanations clear.
Leg ulcer dressings: 27. Mr P’s medical records show he had dressings in place from the district nurses from 3 November, prior to admission to the Trust. A Tissue Viability Nurse (TVN) referral was done on admission and the dressings were not removed until these nurses saw him on 8 November. A TVN is a nurse that specialises in the management of skin wounds. There are no comments from the TVN to say the dressings in place were in poor condition, suggesting there had been no need to redress them prior to this date.
28. For the care of Mr P’s ulcers on the ward, our nursing adviser explained the TVN’s actions were appropriate as they removed the dressings and ensured medical photographs were taken. They have based their advice on their professional judgement. This is because we have not seen specific or general guidance that applies here.
29. The TVN made a recommendation for his next review and dressing change on 11 November. Mr P told us the Trust asked his wife to bring in dressings from home ready for the next change as it did not hold the correct equipment.
30. Mr P was deemed medically fit for discharge on 10 November 2022 and the ward round notes state he was keen to go home. In the LRM, staff discussed his appropriateness for discharge and Mr P confirmed he did not want to stay in hospital any longer.
31. On the care relating to discharge, our adviser explained that NICE guidance NG27 applies. Section 1.5.17 says: ‘The discharge coordinator should arrange follow‑up care. They should identify practitioners (from primary health, community health, social care, housing and the voluntary sector) and family members who will provide support when the person is discharged and record their details in the discharge plan.’
32. Mr P was discharged at 9.50pm on 10 November 2022. Staff made a referral to the district nurses on 11 November at 8.37am asking them to attend the next day to review his leg ulcer dressings. Mr P says he asked his wife to call the district nurses to request they attend on 11 November as he did not feel confident that arrangements had been put in place. The district nurses did attend Mr P’s home on 11 November.
33. Regarding the leg ulcer dressings, we find that Mr P had a TVN review that was appropriate. His leg ulcer dressings were always described as intact in his medical records. On discharge, the evidence shows staff handed care back to the district nurses in line with the guidance.
34. This would then have allowed the next dressing change to take place as planned. We therefore find no failings in this aspect of his nursing care.
Blister dressings: 35. On 6 November, Mr P developed widespread blisters to his abdomen, torso, arms and legs. Mr P said nurses did not attend to his blisters or change his soiled sheets.
36. The ward round on 8 November noted the blisters were bursting due to friction from his clothes. His body maps were completed daily and described blisters across his body. There is no documentation of oozing or leaking of these blisters, or the condition of his sheets.
37. In the LRM, the lead nurse acknowledged that his care should have been better. She said ‘you shouldn’t have been left in blood stained sheets, you shouldn’t have been left in fluid sheets and that is the sort of thing we can learn from.’
38. The first mention of any dressings being applied to his blisters is on the day of his discharge. The nursing notes on this day state Mr P’s back and groin blisters were leaking. The nurse informed a doctor and applied dressings. They explained to Mr P that the blister dressings needed changing PRN (as needed). Mr P says there were three dressings stuck on to his hip.
39. In the LRM, the ward manager acknowledged seeing Mr P on this day of his discharge. She recalls seeing his ‘legs looking a bit of a mess’ and hoping that someone would change his dressings. She confirmed she saw him a few hours before his discharge and did see his dressing were coming off and blood-stained. This is not documented in his medical records. Mr P confirmed these dressings were not changed.
40. We have considered the available evidence. We consider, on balance, it is more likely that Mr P’s evidence and staff recollections provided in the LRM, regarding the condition of his leaking blisters are more reliable than the medical records.
41. Section 1.4.2 of NICE guidance NG27 says: ‘At each shift handover and ward round, members of the hospital-based multidisciplinary team should review and update the person's progress towards hospital discharge.’
42. Section 1.55 says: ‘During discharge planning, the discharge coordinator should share assessments and updates on the person's health status, including medicines information, with both the hospital‑ and community‑based multidisciplinary teams.’
43. Section 1.5.18 says: ‘The discharge coordinator should discuss the need for any specialist equipment and support with primary health, community health, social care and housing practitioners as soon as discharge planning starts. This includes housing adaptations. Ensure that any essential specialist equipment and support is in place at the point of discharge.’
44. As we have explained earlier, the evidence in the records and LRM indicates the Trust did not take care of his blisters earlier in his time in hospital. We find this means the Trust did not meet section 1.4.2 of the guidance to review and update his progress towards discharge.
45. The Trust discharged Mr P on 10 November with a plan for the district nurses to review him. The district nurse referral clearly stated a management plan for his leg ulcer dressings. However, the wound care for his blisters was not mentioned. We find that staff did not comply with section 1.55 of the guidance above as they did not share all necessary information.
46. Mr P’s discharge notes do not indicate that he was sent home with any dressings for his blisters. This was confirmed by both Mr P and the district nursing notes. We find the Trust did not act in line with section 1.5.18 above as it did not ensure specialist equipment was in place.
47. There was a failing by the Trust in the management of his blisters in hospital and on discharge. The evidence shows the Trust did not dress the blisters for a number of days in hospital. It also shows he was not sent home with appropriate supplies or an adequate handover to the district nurses.
Impact
48. Mr P says that the antibiotics, and poor care, caused him eight weeks of pain, discomfort and stress, until he saw the dermatologist. He says he has been left with long-term scarring that causes him embarrassment. Mr P says he felt let down by the Trust and this has affected his mental health.
49. We acknowledge the distress Mr P faced when being sent home with his skin in a poor condition, and with no supplies or advice on how to manage his condition. He told us that he and his wife are both disabled and so anything they have to manage at home is made more difficult.
50. We do not underestimate the impact of his skin condition on Mr P, but we are unable to link the poor communication and dressings with the eight weeks of discomfort until he saw a dermatologist, or with the long-term scarring he faced.
51. We understand the impact of being left with leaking blisters and soiled sheets would have been uncomfortable and distressing for him.
52. Our nursing adviser explained the poor dressings and communication with district nurses on discharge, would have had an impact on explaining what was required of them on Mr P’s discharge.
53. It does seem, despite this, when the district nurses attended him on 11 November, appropriate skin management was implemented. Mr P has told us he does not have concerns about how the care continued with the district nurses.
54. The period of distress Mr P faced from his poor dressings would be from the development of his blisters on 6 November, to the district nurses taking over management on 11 November. This is a period of five days. This is the distress we have found was the impact of the failings.