Nursing care for blisters and wounds
14. Mrs N complains the nursing team did not follow the care plans outlined by dermatology for her mother’s leg and feet blisters.
15. The NMC guidance says nurses should make sure they deliver any treatment, assistance or care for which they are responsible without undue delay. It also says nurses should keep clear and accurate patient records.
16. The dermatology team had set out a care plan for the nurses caring for Mrs F regarding her leg blisters on 14 January 2022. This advised to burst any large and intact blisters in a sterile fashion. It also advised to apply cream daily to Mrs F’s legs and dress them.
17. As such, in line with the NMC guidance, we would have expected the nurses caring for Mrs F to implement this plan and document it in her records.
18. In its response to this part of the complaint, the Trust said there were almost daily entries in the notes between January and March that nurses changed Mrs F’s dressings and applied cream as per the plan from dermatology. It acknowledged that Mrs N felt nurses had not followed the plan but said it appears the correct management was in place.
19. The Trust has reiterated this stance to us. It discussed the case again with the TVN matron who advised that overall, the care provided had been appropriate.
20. Our nurse adviser explained the records in this case are inconsistent and not very detailed. She explained there is evidence to show that on some occasions, the nurses caring for Mrs F had applied dressings and cream. She explained on other occasions, the records do not tell us if this happened.
21. There is also no mention in the records as to whether nurses burst any of Mrs F’s larger blisters. Mrs N tells us this did not happen and has sent us some photographs she took at the time of large blisters which had not been burst.
22. Our nurse adviser explained she was unable to comment on whether it was appropriate to burst blisters as her usual practice would to be keep blisters intact. She said this is because they provide a sterile environment for wounds. We sought TVN advice regarding this who advised they were unaware of any national guidance advising to burst blisters.
23. We have seen at least one documented occasion in the medical records on 7 February where Mrs N raised concerns with the nurses regarding her mother’s legs not having dressings on them. The nurses documented they explained to her that due to the blisters leaking the dressings would become saturated, increasing the risk of infection. The nurses documented they would discuss this with dermatology.
24. The NMC guidance says nurses should refer matters to their colleagues where appropriate. As such, if the nurses implementing the care plan previously set out by dermatology were having issues in doing this, we would have expected them to contact dermatology again for further advice. We can see no evidence this then happened even though a nurse documented they would do so on 7 February.
25. We have considered Mrs N’s account of what she witnessed as well as the advice from our nurse adviser and Mrs F’s medical records. We have also considered the Trust’s view that the nurses did follow the plan. Taking everything into account, we have found the nurses did not always follow the care plan which was set out by dermatology on 14 January during Mrs F’s stay.
26. We acknowledge, as stated by the Trust, that there were many occasions documented where nurses did follow the care plan by applying the cream and keeping Mrs F’s legs dressed. However, we have found this was inconsistent and not always fully documented in the records in line with the NMC guidance. This was a failing.
27. Mrs N tells us her mother suffered in pain due to the issues with her legs and the inadequate care. She said that her mother had oozing sores and blisters which affected her mobility. She says the memory of this has affected the entire family.
28. We have reviewed Mrs F’s medical records, and we can see many instances where she advised nurses she was not in any pain. However, we can also see some instances in the medical records where Mrs F was in pain with her leg blistering. Our nurse adviser said that not managing her wounds and blisters correctly could have contributed to this as when not managed correctly, blisters will not heal.
29. It is understandable that her mother not always receiving adequate care for her leg blisters and seeing her in pain would have been distressing to Mrs N. As stated above, the Trust has not acknowledged any failings regarding this in its response to Mrs N’s complaint.
30. Although at the end of its complaint letter dated 20 June 2023, the Trust offered a general apology to Mrs N for her mother’s experience and said it had shared learning from the complaint, we do not think this does enough to address this specific issue.
31. We also recognise that in response to us considering the complaint, the Trust has detailed some service improvements within its TVN service since the events. However, given that this complaint is about the general nurses’ implementation of the plan and not about the TVN team, we do not feel these changes are enough to address the issue we have identified either. We have made some recommendations to the Trust below to help address this further.
Visiting during end of life
32. Mrs N told us during a consultation on 11 April a doctor advised her that her mother was to be placed on an end-of-life care pathway. She told us she asked the doctor if she could stay with her mother, but the doctor declined this request. She said following this consultation, she also asked a nurse if she could stay but the nurse advised she could not as her mother’s death was not imminent.
33. Mrs N was in hospital whilst the COVID-19 pandemic was still ongoing and there were still some restrictions regarding visitation.
34. The COVID-19 visiting guidance provided advice to hospitals at the time of these events. This said organisations should take a compassionate approach in balancing the importance of close family members being able to spend precious time with a dying patient against the risk of managing infection. It said organisations, in conjunction with the local incident team, should use their own risk-based assessment to decide to what extent it could facilitate more relaxed visiting arrangements.
35. In its response to this part of Mrs N’s complaint, the Trust said during the COVID-19 pandemic, it supported visiting in a safe manner for patients at the end-of-life stage. It said the records show a conversation took place between Mrs N and a respiratory consultant on 11 April at 2.40pm. It said the consultant documented Mrs F was for end-of-life care.
36. It said there was no documentation following this conversation in relation to visiting arrangements. It said it would have assumed that as Mrs F was for end-of-life care, arrangements would have been put in place for extended visiting. However, it said due to the amount of time passed, it was unable to comment further.
37. We have reviewed the medical records, and we also cannot see any documented evidence of Mrs N asking the nurse if she could stay. However, we have no reason to disbelieve Mrs N that she asked this. She has provided a consistent account throughout her complaint to the Trust and to us.
38. Regardless, it is clear from the records that on 11 April, the clinical team considered Mrs F to be an end-of-life care patient. As such, in line with the COVID-19 visiting guidance, we would have expected those caring for her to consider if Mrs N could have more relaxed visiting. We can see no evidence the Trust made any attempts to arrange this which we consider to be a failing.
39. We understand how painful it is for Mrs N that her mother died a short time after this without her being present. She is concerned her mother would have been frightened. We can see how upsetting the knowledge that her mother died alone is to her and that this is a continued source of distress.
40. As stated, above, the Trust said in its response that as Mrs F was for end-of-life care it would have expected arrangements to be put in place for extended visiting. It acknowledged there is no documentation in the records about this and so said it was unable to comment further.
41. In its comments to us, the Trust said it had already offered an apology to Mrs N for this issue. However, whilst the Trust offered an apology that Mrs N was not able to be with her mother, it did not acknowledge that this was a result of a failing by the Trust. As such, we do not agree that this was a sufficient apology.
42. We do not feel this response goes far enough to address this failing and the impact it had on Mrs N. We have made some recommendations to the Trust below to address this.