Mr F’s consultation at the Surgery
19. In her complaint to us, Mrs F said the Surgery’s staff put the seizure her son reported down to him taking an extra dose of pregabalin (we give more information about this drug in paragraph 24). She considers his seizure was a sign of his cancer, and staff should have sent him to hospital to investigate the cause of his seizure.
20. In its complaint process, the Surgery said staff suspected Mr F had his seizure because he took an additional dose of pregabalin. Therefore, staff referred him to the oncall medical team at the local single point of access (SPA) service about investigating his seizure. It said the SPA service decided to refer him to the seizure clinic.
21. We found the Surgery acted in line with guidelines on this matter.
22. Section 15a in Good Medical Practice says, if doctors assess, diagnose, or treat patients, they must adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient.
23. In line with this, Mr F’s records on his consultation show the doctor he saw obtained a history from him about the problems he sought help with. The doctor recorded he reported:
• pain in his neck and left shoulder lasting four to five months • the pain was worsening and now affecting his day-to-day life • tingling and numbness in his left arm • he played computer games frequently • he had a history of substance abuse • two days before his consultation he had a seizure after taking a third dose of pregabalin (which he obtained independently without a prescription from a licensed doctor), when he normally took two doses per day • he did not fall or injure himself when he had his seizure.
24. Pregabalin is a drug only available on prescription. It has different uses. Doctors can prescribe it:
• in epilepsy to prevent seizures by reducing abnormal electrical activity in the brain • to manage nerve pain by blocking the pain messages travelling through the brain and down the spine • to manage anxiety by stopping the brain from releasing chemicals that make someone feel anxious.
25. Our GP adviser said the history the Surgery’s doctor documented contained lifestyle factors which were relevant to the cause of the seizure Mr F reported. They recorded when his seizure happened and what happened just before it. The doctor also documented where Mr F reported his ongoing pain and its duration.
26. Mr F’s records show the doctor did physical examinations too. This included exploring his range of movement where he reported pain. They also measured Mr F’s blood pressure as 135 over 88 in millimetres of mercury (mmHg).
27. Through their assessment, besides Mr F’s pain, the doctor established he had experienced a first seizure. Our GP adviser said the information the doctor gathered supported this conclusion.
28. Section 15b and 15c in Good Medical Practice say, when establishing a diagnosis, doctors should promptly arrange suitable investigations or treatment. This can involve referring a patient to another practitioner where this serves their needs.
29. Our GP adviser said, relevant to what the doctor found, section 1.1 of NICE Guideline 217 says, after a first suspected seizure, staff should refer a patient to a clinician with expertise in assessing first seizures and diagnosing epilepsy.
30. Mr F’s GP records show this is what the Surgery’s staff did. After consulting the SPA service, they referred Mr F to the first seizure clinic at Hospital A. Through this action, the first seizure clinic contacted him by text to share an appointment booking letter for the assessment. In paragraph 11, we explained what service this clinic provides.
31. Having considered the evidence and advice, we saw the Surgery acted in line with guidelines. After assessing Mr F in line with Good Medical Practice, its staff made the referral NICE Guideline 217 recommends based on the diagnosis they established.
32. We recognise Mrs F considers the Surgery missed an opportunity to arrange earlier investigations she believes may have detected her son’s cancer.
33. We hope our findings clearly explain why we saw the Surgery acted in line with guidelines when he first reported having a seizure. We hope this helps to give her some assurance on what we appreciate are difficult events for her to reconcile.
Mr F’s ED admission at the University Trust
34. Responding to Mrs F’s concerns ED staff did not investigate her son’s seizures, the University Trust said Mr F presented at its ED with a right arm injury following a fall earlier that day in his bedroom. The X-rays staff did showed he fractured his humerus.
35. It added, through consultation with the orthopaedic team, staff planned for him to have a plaster cast and a repeat X-ray. It said staff booked him a follow-up appointment in the fracture clinic to have the repeat X-ray.
36. The University Trust said Mr F had no head injury or loss of consciousness resulting from his fall. It said he did not report seizures. It added he presented with an isolated arm injury following a fall and he was clinically well. It said there was no indication for blood or urine tests. It said, based on the information available to staff at the time, they appropriately dealt with the humerus fracture he presented with.
37. We found staff acted in line with guidelines on this matter.
38. Our ED adviser said staff should have acted in line with section 15 of Good Medical Practice in assessing, diagnosing, and treating Mr F. We explained what these guidelines say in paragraph 22 and 28.
39. In line with section 15a of Good Medical Practice, Mr F’s ED records show staff obtained a history from him about the problem he sought help with. Staff noted Mr F reported he fell in his bedroom that morning and landed on his right arm. He reported no head injury or loss of consciousness at the time he fell. He did not report having had seizures.
40. Staff noted he had three hip replacements previously. He shovelled when he walked, which created mobility issues for him. He was awaiting further review for his hip at the Royal Orthopaedic Hospital NHS Foundation Trust (the Orthopaedic Trust).
41. Staff examined the arm he fell on. They checked for tenderness and his range of movement from his fingers to his upper arm. Through these examinations, staff identified he had a reduced range of movement and pain in his upper arm.
42. Our ED adviser said this assessment supported the conclusion staff reached that Mr F suffered an isolated arm injury. The information they gathered suggested his known mobility issues, for which he had existing support planned (at the Orthopaedic Trust), explained his fall. On this basis, our ED adviser said a suitable investigation to assess the extent of his arm injury was an X-ray.
43. Therefore, staff acted in line with section 15b of Good Medical Practice in arranging an X-ray while Mr F was in the ED.
44. Radiologists reported Mr F’s X-ray showed he fractured his right humerus. Our ED adviser said his fracture was consistent with the type of injury they would expect to see when a patient falls and lands on their arm.
45. Based on these findings, Mr F’s ED records show, following consultations with orthopaedic colleagues, ED staff fitted him with a plaster cast and sling on his arm to manage his injury. They then felt, as he reported no other concerns, he was well enough to go home.
46. That said, staff booked him a follow-up appointment at the fracture clinic the following week with a plan to fit him with an arm brace, do a repeat X-ray, and to consider any other management he may need.
47. Our ED adviser said this initial treatment and the management plan following Mr F’s discharge was in line with what they would expect to see.
48. Therefore, we saw staff acted in line with section 15b and 15c of Good Medical Practice in the care they gave Mr F, and in deciding to discharge him with planned followup appointments as an outpatient at the fracture clinic.
49. Mr F’s ED records confirm, and our ED adviser said, he reported no history of recent seizures or other symptoms which staff should have investigated further. Therefore, we did not find staff received information which meant they should have done the tests Mrs F says they needed to do to investigate seizures her son said he had.
50. Relative to what she told us, we consider the information in Mr F’s records is more compelling evidence about what happened. These are records from the time made by staff who were with Mr F which document what he told staff while he was in the ED.
51. Having considered the evidence and advice, we found staff assessed Mr F and arranged investigations into the injury he reported in the way Good Medical Practice recommends. They reached a diagnosis based on this assessment. They then arranged suitable treatment to manage this injury, including as an outpatient after his discharge.
52. As this is all in line with Good Medical Practice, we saw no failings in the investigations staff decided to do or in their decision to discharge Mr F.
53. We recognise Mrs F considers ED staff missed a chance to find her son’s cancer. Therefore, we appreciate our findings will be disappointing for her.
54. We hope we have clearly explained our findings, and they help give her some assurance about the care her son received at the University Trust.
Skincare
55. Responding to Mrs F’s concerns on this matter, Sandwell Trust said staff conducted daily skin assessments while her son was in hospital from 25 August 2022. It said these assessments showed bruising to his arms, redness to his buttocks, and blisters and peeling skin on his leg in early September.
56. On this basis, ward staff referred him for input from the tissue viability team. Sandwell Trust said this team then managed his skin breakdown in line with tissue viability guidelines. This included taking actions like applying dressings to the affected area.
57. Mrs F told us she noticed unpleasant smelling sores on her son’s skin. She considers staff did nothing to manage them, and this could not be right.
58. We found staff acted in line with guidelines on this matter.
59. Section 1.1 in NICE Guideline 179 says, to assess the risk of skin breakdown, staff should conduct and document an assessment of pressure ulcer risk for patients when staff admit them to hospital. Staff should reassess pressure ulcer risk if there is any change in the patient’s clinical status. For example, after surgery, if their underlying condition worsens, or if their level of mobility changes.
60. If staff assess a patient as being at high risk of developing a pressure ulcer, they should offer the patient an assessment from staff with specialised skincare training. In their assessment, these staff should take account of any pain or discomfort the patient reports and check their skin for:
• skin integrity in areas of pressure • colour changes or discoloration • variations in heat, firmness, and moisture (for example, because of any incontinence, oedema (swelling caused by fluid build-up in the body), dry or inflamed skin).
61. Staff can consider the following measures for patients they identify as being at risk of developing pressure ulcers to try and prevent them:
• encourage the patient to frequently reposition themselves, or assist them to do so if the patient cannot do this independently • nutritional supplements and hydration (if the patient does not take in adequate nutrition or fluid themselves) • pressure redistributing devices (like mattresses that redistribute pressure) • barrier creams (to prevent skin damage in patients at high risk of developing a moisture lesion or incontinence-associated skin damage).
62. When staff admitted Mr F to hospital, his care records show nurses asked whether they could perform a skin assessment during the evening of 24 August. Mr F declined this assessment and told staff his skin was intact.
63. As a patient who could communicate his needs and had capacity to make decisions about his care, staff did not do the skin assessment. Staff recorded Mr F continued to tell them his skin was intact when they enquired about this each day for the rest of August.
64. As an adult with capacity to make decisions, our nursing adviser said Mr F was within his rights to decline skin assessments during this period. Section 2.5 of the NMC Code says nursing staff must respect, support, and document a person’s right to accept or refuse care and treatment.
65. Therefore, staff acted in line with these guidelines in enquiring about doing skin assessments, but respecting Mr F’s wishes that he did not want to have them.
66. On 1 September, Mr F’s care records show he permitted staff to do a skin assessment.
67. In this assessment, staff noted some bruises on his arms and legs, redness on his buttocks, and a blister on his right leg with some peeling skin. They continued to reassess this daily, and our nursing adviser said they dressed the blister when required. Mr F’s records do not show this blister deteriorated and developed into a wound.
68. On 4 September, Mr F and staff noted a blister on his left leg which was getting worse and causing swelling. His records show staff referred him to the tissue viability team about this blister. Our nurse adviser said they would expect to see such a referral at this stage given the changes and evidence of the new blister which was worsening.
69. On this basis, we saw staff acted in line with NICE Guideline 179 here.
70. They continued to reassess the risk of Mr F’s skin breaking down when he started consenting to these assessments from 1 September. When they saw deterioration in his skin integrity and staff considered his risk of further skin breakdown was increasing, they offered him an assessment from skincare specialists. That is, Sandwell Trust’s tissue viability team.
71. At 9.12am on 5 September, tissue viability staff assessed Mr F. In their assessment, they checked his skin and noted where he had skin breakdown. That was, at the site of the blister on his left leg where he now had an exuding wound 1cm by 2cm in size.
72. To manage this wound and minimise further skin breakdown, tissue viability staff encouraged Mr F to elevate his leg. They also applied an absorbent dressing pad with alginate which they secured to his wound.
73. Alginate is a gel derived from seaweed. The BNF Guidance (the section on alginate dressings) recommends staff use dressings like this on exuding wounds. When they are in contact with a wound these dressings promote healing.
74. So, in line with NICE Guideline 179, this evidence shows specialised skincare staff assessed Mr F’s risk of skin breakdown and pressure ulcers. Through their assessment, they planned measures recommended by this guideline to manage the issues they identified. Our nursing adviser also said this was the kind of assessment and plan they would expect to see.
75. From this point, our nursing adviser said they saw frequent entries in Mr F’s care records on staff implementing these measures. This included assisting him to elevate his legs when he was struggling, repositioning him, and later applications of barrier creams. We note these actions are all in line with NICE Guideline 179.
76. What our nursing adviser did not see was consistent entries specifically about staff changing Mr F’s wound dressings. That said, they considered it was likely staff checked and changed his dressings frequently but did not explicitly record this. They said they saw staff frequently mentioned his skin integrity in his records, which suggested staff monitored this.
77. Our nursing adviser also said the wound on his left leg likely became larger and deeper as his underlying clinical condition worsened over time. They added his previous history of injecting drugs into his veins would not have helped either. Therefore, the progressive breakdown of his wound was likely unavoidable.
78. From our review of Mr F’s records, we saw staff noted specific reference to his leg wound and/or his dressing on:
• 11 September (when his wound was leaking, and nurses asked doctors to assess him) • 16 September (when his dressing was in place and intact) • 17 September (with his dressing in place and it was dry and intact) • 19 September (his dressing was dry, clean, and intact, but staff fitted another dressing for him) • 20 September (staff changed his dressing, they also asked tissue viability colleagues to review him again, who advised staff to continue using the dressings) • 22 September (staff changed the dressing on his leg) • 26 September (the tissue viability team assessed Mr F’s wound again after his most recent alginate dressing adhered to his wound, which was getting larger, and they recommended staff switched to using larger non-adherent silicone dressings) • 28 September (staff cleaned his wound and put a new dressing on).
79. So, when there was a significant change with his wound staff noted this. For instance, after recording deterioration on 11 September, staff noted Mr F’s wound improved and his dressings were dry and intact by 17 September. Given the documentary evidence of this progress, and his dry dressings, we concluded staff frequently checked and changed his dressings.
80. After that, we saw more frequent reference to staff checking and changing his dressings. When they had concerns about his dressing adhering to his wound, staff asked the tissue viability team to review him. Tissue viability staff then changed the type of dressings.
81. The BNF Guidance (the section on soft polymer dressings) says staff can use the type of dressings they switched to so they can manage an exuding wound like Mr F’s.
82. Therefore, we concluded this shows staff were monitoring the status of his dressings and their interactions with his wound and changing his dressings when needed.
83. Also, as our nurse adviser said Mr F’s wound got larger as his clinical condition progressed, deterioration in his wound does not necessarily show a failure to monitor his wound and change his dressings. Weighing this up with the evidence above that staff checked and changed his dressings, we found it is more likely Mr F’s wound worsened as his health got worse, not because of poor skincare.
84. So, having considered the evidence and advice, we found staff conducted the risk assessments for Mr F’s skin integrity NICE Guideline 179 recommends when he permitted these assessments.
85. Through these assessments, staff planned measures these guidelines recommend to reduce the risk of further skin breakdown. They also provided wound care in line with the BNF Guidance for the wound on his left leg when this developed.
86. We recognise Mr F’s skin integrity worsened during his admission. This must have been very distressing for Mrs F to see.
87. We hope we have clearly explained our findings on this matter and how we reached them. We hope our review helps to assure Mrs F staff were taking actions to try and manage her son’s skin integrity.
Washing and personal hygiene
88. Responding to Mrs F’s concerns on this matter, Sandwell Trust said staff offered her son support with washing. It added he had a basic wash most days during his admission and normally he needed minimal assistance with this. However, sometimes he refused a wash. Therefore, as a patient with capacity to make his own decisions, staff respected his wishes.
89. We found staff acted in line with guidelines on this matter.
90. Section 1.2.9 in NICE Guideline 138 says staff should ensure they regularly review and address a patient’s personal needs. For example, their continence, personal hygiene, and comfort. They should regularly ask patients who are unable to manage their personal needs what help they need. Staff should address their needs at the time of asking and ensure maximum privacy.
91. Section 1.2.12 says staff should obtain consent from the patient to provide any support like this.
92. On admission to hospital, staff assessed Mr F as a mobile, independent, and selfcaring patient. His care records show, in the earlier stages of his admission, he was independent with all his hygiene needs. When he could attend his own needs, he said he did not want help from staff with this. Therefore, staff allowed him to manage his own needs.
93. As a patient who was able to and wanted to manage his own hygiene needs at these times, it was in line with NICE Guideline 138 for staff to allow him to do this. Our nurse adviser said they would expect to see staff allowing Mr F to manage his own needs here.
94. Later in his admission, when he became more unwell and he could not manage independently, our nurse adviser saw staff assisted him at these times. Our nurse adviser explained assistance with hygiene can mean various things. This can range from staff giving a patient a bowl of warm water to wash in, to assisting them in the bathroom, and helping them have a shower.
95. From our review of Mr F’s care records, we saw staff enquired about his ability with hygiene tasks each day. Although his ability fluctuated, staff recorded he was self-caring for most of his admission. That said, we saw entries when staff supported him with personal care tasks after gaining consent to do so. This included:
• on 15 September when he had low mood • on 16 September when staff assisted him to use the shower • on 22 September when staff assisted him to use the bathroom • on 26 September to 28 September when staff assisted him with all personal care tasks after his oxygen saturation levels deteriorated and he needed supplemental oxygen.
96. As entries staff recorded at the time of events, we consider his care records are compelling evidence Mr F could manage his own personal care most of the time. At these times staff allowed him to manage his own needs. When this evidence showed he needed more assistance, staff supported him with personal hygiene tasks when he consented to this.
97. As the evidence and advice shows staff acted in line with NICE Guideline 138 in supporting Mr F with washing and his hygiene, we saw no failing on this matter.
98. We recognise Mrs F considers staff did not do enough to support her son with these needs and she found this distressing.
99. We hope we have clearly explained our findings and why staff acted in line with guidelines.
Mr F’s cast
100. In the first instance, we saw conflicting evidence about what happened on this matter. Mrs F told us staff at Hospital B removed a cast her son had fitted on his arm. Mr F’s care records show staff removed a humeral brace fitted on his arm and replaced it with another humeral brace.
101. Noting such a distinct conflict here, we weighed up the evidence on this matter to consider, on the balance of probabilities, what happened.
102. As we explained in paragraph 45 and 46, Mr F’s records from the University Trust show ED staff fitted him with a plaster cast and sling for his arm on 23 July. The University Trust’s records on the follow-up appointments he attended at the fracture clinic show staff removed his cast in the clinic on 26 July. They replaced his cast with a humeral brace.
103. Later records on his fracture clinic appointments show he was still wearing the brace at the final appointment he attended on 2 August. Mr F did not attend the appointments after that which staff arranged from 16 August.
104. Our orthopaedic adviser said a humeral brace consists of canvas or other flexible material that wraps around the upper arm of a patient. Staff can secure the brace in place with straps. Braces usually have longitudinal rods or plastic shells built into the structure to provide rigidity and support for the fractured humerus.
105. Braces reduce bending and movement at the site of the patient’s fracture. They are lighter than a plaster cast and designed to be more comfortable to wear for a patient.
106. When Mr F attended the ED at Hospital A on 24 August and staff admitted him to hospital, his records show staff saw he was wearing a sling. His records throughout late August and into September continue to document Mr F had a sling in place.
107. On 9 September, an entry from orthopaedic staff shows, following further scans on his arm, they fitted Mr F with a humeral brace. Mr F’s records show staff transferred him to Hospital B on 16 September.
108. His records there show orthopaedic staff later discussed further treatment options for his fracture with Mr F and his family. This was around 1.30pm on 21 September. As staff found he had incurable cancer by this point, and its spread was affecting how his fracture healed, Mr F opted not to have surgery. He agreed to continue conservative management of his fracture (we explain what conservative management is in paragraph 117).
109. Following this discussion, staff took him to the plaster room around 45 minutes later. Our orthopaedic adviser said his records show staff removed the humeral brace he had on and replaced it with a new one. His records show staff did not remove or apply another fitting like this before they transferred him to a local hospice on 28 September.
110. Following our review of all this information, we saw the documentary evidence from the time shows the only item staff in Hospital B removed from Mr F’s arm was his humeral brace on 21 September.
111. His records show family members were in hospital at the time. Therefore, Mrs F is likely to have seen the fitting on her son’s arm before and after his visit to the plaster room. Given the appearance of these braces as described by our orthopaedic adviser, we can see how a lay person might use the term ‘cast’ to describe what Mr F had fitted on his arm before his visit.
112. Our orthopaedic adviser also said there are many different types of humeral braces available. They can look very different, but they work in the same way. Therefore, the brace staff fitted at Hospital B may have looked different to the one they replaced.
113. Reflecting on this, we saw how replacing a brace may have come across as a significant change to Mrs F.
114. Considering how this documentary evidence from the time fits with what Mrs F complains about, and where it happened, we decided this is compelling evidence this is the event she complains about. Therefore, we considered whether staff acted in line with guidelines in removing Mr F’s humeral brace and replacing it with a new one on 21 September.
115. Having done so, we found staff acted in line with guidelines.
116. The opening section of the Humeral Fracture Guidance says conservative management is the treatment of choice for most humeral fractures to help them heal. This offers functional results and union rates (of broken bones) that are not inferior to surgical management.
117. Our orthopaedic adviser said conservative management of a fracture like Mr F’s means staff do not operate on the fracture but treat it using a plaster cast or a humeral brace. In some cases, a patient may not need either of these things and staff can treat the fracture by applying a sling. These devices support and stabilise the fracture and help the broken bones unify so a patient’s fracture heals.
118. We also saw the conservative management section of the Humeral Fracture Guidance recommends staff use humeral braces as part of this conservative treatment approach. Therefore, staff in Hospital B were using a treatment approach recommended by the Humeral Fracture Guidance to manage Mr F’s humerus fracture.
119. Our orthopaedic adviser said the use of a brace is in line with what they would expect to see as part of a patient’s treatment for a fracture like Mr F’s. They added, as time progresses, staff need to remove a patient’s humeral brace from time to time. This is so staff can wash the brace and provide skin care in the area the brace covers.
120. Mr F’s records show staff applied a fresh brace in place of the old one. Staff in Hospital A had fitted the old one almost two weeks earlier. While he was in the plaster room, staff checked the integrity of his skin covered by the brace when they changed it.
121. Therefore, after considering the evidence and advice, we found staff continued a treatment approach recommended by the Humeral Fracture Guidance. That is, replacing Mr F’s humeral brace. As the brace staff removed made way for a fresh one, we saw no failing in his care.
122. We recognise Mrs F is concerned staff did not fit the devices her son needed to help manage his fracture.
123. We hope we have clearly explained our findings on this matter and how we have come to them. We hope our review on this matter and the other concerns Mrs F raised give her assurance about the care her son received, and we gave all her concerns careful consideration.