University Hospitals of Leicester NHS Trust
ED Delay 14. Mr E complains that on 14 October 2022 the Hospital Trust delayed admitting his wife, to the ED because ambulances were backed up. He says this delayed the Hospital Trust assessing his wife and a poor level of care before being diagnosed with sepsis.
15. Mrs E arrived at the ED at 8.56am and was moved from the ambulance into an assessment bed at 10.41am. This means it took 45-minurtes for her to be admitted to hospital once the ambulance had arrived. While there are no specific guidelines about how long this should take, the Hospital Trust explained at the time of Mrs E’s arrival at hospital, they were experiencing significant pressures leading to unacceptable waits for patients.
16. We looked at whether this impacted the care given to Mrs E during this time. We saw that a senior clinician reviewed Mrs E on the ambulance while she was waiting to be taken into ED. They carried out basic safety checks. During the one hour 45-minute delay in Mrs E being admitted the paramedics also monitored her in the ambulance.
17. NICE, NHS England and NHS Improvement advise the use of NEWS2, a track and trigger early warning score system that is used to identify and respond to patients at risk of deterioration. Our adviser explained this is widely used in acute and ambulance settings.
18. NEWS2 uses monitoring of respiratory rate; oxygen saturation; temperature; systolic blood pressure; pulse rate; level of consciousness. A score is allocated to each, with a higher value indicating a higher risk of deterioration. Clinicians then make decisions about care and treatment using this alongside clinical assessment. The Trust used this in Mrs E’s case while she was in the ambulance waiting to be admitted.
19. This means that despite the delay in the ambulance, the Trust did follow relevant guidance to assess and monitor Mrs E during this period as it would have, had she been admitted to the ED. This was in line with NICE and NEWS2 guidance and it also carried out regular senior clinical assessments.
20. We empathise and understand that this experience was very distressing for Mr E and his wife. We hope he is reassured that we have not seen any evidence this delay in admitting her to the ED caused any deterioration or delay in diagnosis as she was still being seen, assessed and monitored in the ambulance. Mrs E was diagnosed with sepsis later on the ward, but this initial delay does not appear to have specifically impacted this as they would still have had to wait for her to be seen by a specialist clinician even had she been in the ED.
21. The Hospital Trust has apologised for the delay and explained the reasons for the delay were due to high demand at the time and its capacity to take patients. It appears that despite this the Hospital Trust kept patients as safe as possible in a time of pressure ensuring a senior clinician reviewed Mrs E and carrying out basic safety checks. We were also reassured to hear, due to Mrs E raising a compliant to the Hospital Trust about her experience in October 2022, it has taken positive action and created extra cubicle space for patients, which it said has led to fewer patients waiting on an ambulance for prolonged periods of time.
22. Our Principles say we would expect organisations to acknowledge mistakes and apologise for the impact these mistakes had. We would also expect organisations to take action to learn and improve from mistakes. By apologising and taking action based on Mrs E’s complaint, we believe the Hospital Trust has acted in line with our Principles to address the issues identified. Therefore, we will not be taking further action to investigate this complaint and hope our explanations give Mr E some reassurance about what the Hospital Trust did
Pressure sore 23. Mr E complains when his wife was admitted for treatment and she suffered pressure sores, was neglected and received poor care.
24. NICE guidelines on pressure sores say clinicians should carry out risk assessments, skin assessment, repositioning and use pressure relieving devices.
25. The first record of Mrs E having signs of pressure sores was at the Hospital Trust on 21 October 2022 when she had a purple non-blanching area on her buttocks. A tissue Viability Nurse (TVN) reviewed her and made treatment care plans for repositioning every two to four hours, a pressure relieving mattress and sitting out in her bed side chair on a pressure relieving cushion. This is in line with the above NICE guidance.
26. Despite this by 24 October Mrs E had developed a pressure sore to her sacrum which had developed onto both buttocks. The affected area and surrounding skin was treated. Repositioning was increased too every two to four hours. They also advised Mrs E should not sit out, and she could sit on the edge of the bed for meals and strengthening exercises.
27. Our advisor explained there are many risk factors for pressure sores including reduced mobility, nutritional deficiency, older age, and conditions that cause inadequate blood flow to the skin and soft tissues (such as diabetes and peripheral vascular disease). Mrs E had several long-term conditions which could have impacted on her pressure sores not improving, including diabetes, lupus, anaemia and cerebral palsy.
28. Our adviser explained there are no specific guidelines for repositioning patients that have stage four pressure sores, however there is general guidance around the repositioning of patients at high risk of developing pressure sores. This category includes Mrs E, who would be classified as high risk.
29. NICE guidelines on encouraging adults who have been assessed as being at high risk of developing a pressure sore to change their position frequently and at least every four hours. If they are unable to reposition themselves, staff should offer help to do so, using appropriate equipment if needed. They should also document the frequency of repositioning required.
30. Based on the records from the Hospital Trust it appears Mrs E was repositioned every two to four hours in line with the TVN advice from the Hospital Trust and the NICE guidance above.
31. Sadly, Mrs E developed pressure sores which continued to deteriorate despite the Hospital Trust taking action to try to prevent this from happening. As we explained above sometimes existing conditions can mean that patient’s get pressure sores which cannot be avoided. It seems this happened in Mrs E’s case and it must have been very distressing for her and her family to see. We hope our explanations have given some reassurances. We have also dealt with the care of the pressure sores later in the Partnership Trust section when she was a patient there.
MRI Scan 32. Mr E says on 25 January 2023 the Hospital Trust failed to identify that his wife’s wound dressings containing particles of silver before it completed an MRI scan. He explained this caused her discomfort and could have possibly caused burns had the scan not been aborted mid-way. Mr E is looking for an apology and some compensation for the effects on her physical and mental health due to the situation. We can clearly see that what happened when Mrs E had the MRI scan would result in the frustration anxiety and emotional distress described.
33. MHRA guidance says patients should be screened before entering the MRI environment by a suitably trained and experienced member of MRI unit staff who knows the clinical safety aspects of exposure to MRI equipment. Our advisor explained that in this case the radiographer was responsible to ensure patient safety.
34. The Hospital Trust’s radiographer went through an MRI questionnaire with Mrs E to ensure it was safe to undergo the scan in line with the above guidance. Mrs E answered no to all questions, apart from ticking she was a diabetic and have allergies to penicillin, iodine, codeine and plasters.
35. Mrs E confirmed she had a drug patch on, which was removed before the scan in line with the safety guidelines. When going through the questionnaire, Mrs E did not mention she had a pressure sore or there was a dressing covering the wound. Had this been identified at the time of the scan, the radiographer would have been expected to investigate this further before putting Mrs E onto the scanner. As it appears this was not mentioned they could not do this. While in the scanner Mrs E informed the radiographer that she was uncomfortable in the scanner, her scan was aborted.
36. It is understandable from what Mr E has told us the distress his wife experienced when having the MRI scan. We understand how frustrating this must have been, and it is clear this was a very difficult for Mr E, his wife and their family and we are sorry for their experience.
37. We have not seen evidence that the Hospital Trust did anything wrong regarding its preparation for the MRI. It completed the assessment in line with the guidelines as explained above and the scan was stopped as soon as Mrs E said she had discomfort, so she was not burned. We will not be taking further action to investigate this complaint and hope our explanations give Mr E some reassurance about what the Hospital Trust did.
Leicestershire Partnership NHS Trust
Pressure sore 38. Mr E complains the Partnership Trust managed his wife’s pressure sores poorly and did not reposition her enough. He explained he was concerned about this because she was not often repositioned within the expected two to four hours and was being repositioned on occasion at six to eight hours.
39. Mrs E was transferred to a hospital at the Partnership Trust on 15 November. At this point her pressure sores were categorised as ‘unstageable’ which is a type of pressure sore that cannot be visually staged due to the presence of a layer of dead, dried tissue that covers the sore. Between her admission on 15 November and discharge on 15 December Mrs E’s pressure sore developed to a stage four.
40. Stage four pressure sores are the most serious type that damage the muscle and bone, and sometimes the tendons and joints. They are caused by prolonged pressure on the skin, usually over bony areas. They extend below the subcutaneous fat into the deep tissues and can even reach the cartilage or bone. They have a high risk of infection and are difficult to treat. She continued with stage four pressure sores until her discharge on 15 December.
41. As explained above, our adviser said Mrs E would have been classified as high risk and NICE guidelines say patients should change their position frequently and at least every four hours and staff should document the frequency of repositioning required. The TVN had increased this frequency to every two to four hours.
42. Based on the records from the Partnership Trust it appears Mrs E was repositioned every two to four hours most of the time. This would have been in line with the TVN advice from the Hospital Trust and the NICE guidance above. However, there were occasions when there were longer gaps between repositioning and checks. This is not in line with the guidelines above.
43. NICE guidance also recommends the use of appropriate wound dressings. The choice of dressing should take into account: • the person’s pain and tolerance level • the position of the ulcer • the amount of exudate • frequency of dressing change • consider using a dressing that promotes a warm, moist, wound-healing environment to treat Category II, III, and IV pressure sores • do not offer gauze dressings to treat a pressure sore.
44. Our advisor explained there are many types of dressing that can be used for pressure sores. However, it would depend on what grade the wound was categorised as and what the clinical features were. In Mrs E’s case, a comprehensive assessment was undertaken by the TVN, and she was reviewed regularly, with the treatments, including dressings, being adapted to the condition of her wound during that time. Mrs E’s wound was mainly being dressed using Flaminal forte and Flaminal hydro gels, and Suprasorb gentle border dressing. Our adviser explained these would have been specifically chosen to help with the exudate and sloughiness of her wound and promote the healing of the skin.
45. Based on the evidence we have seen it appears the Partnership Trust did not act in line with NICE guidelines with how often it repositioned Mrs E, but it did treat the pressure sores in line with guidelines using different dressings.
46. It is understandable, from what Mr E has told us, why he felt the care and treatment his wife received from the Partnership Trust was inadequate and the anxiety and distress this cause him, his wife and his family.
47. We hope that he is reassured that despite his wife not always being repositioned within two to four hours this is unlikely to be the reason for her pressure sore’s deterioration. This is because the majority of the time, she was being repositioned and her wounds were being treated with correct dressings. She was also being monitored and on pressure relieving equipment, but sadly this could not improve her pressure sores.
48. Our Principles say we would expect organisations to acknowledge mistakes and apologise for the impact these mistakes had. We would also expect organisations to take action to learn and improve from mistakes. The Partnership Trust acknowledged that on occasions staff did not meet the two to four hourly repositioning and apologised. This appears to have addressed the distress and upset caused at some repositioning not being in line with the guidelines.
49. We will not be taking further action on this complaint and hope our explanations give Mr E some reassurance about what the Partnership Trust did and that it has acknowledged and addressed the upset it caused.
Covid-19 50. Mr E complains the Partnership Trust moved his wife from a side room to a bay with other patients. He said the reason for the move was not discussed or communicated to him or his wife at the time which caused them anxiety and distress. He said he felt safer and so did his wife, being in the side room because of the situation with Covid-19 at the time and because his wife had a very low and compromised immune system and was scared of catching it.
51. He explained the Partnership Trust later admitted a patient to the bay who then tested positive for Covid-19 and then so did his wife. Mr E said this meant his wife had to self-isolate once discharge home on 15 December 2022 and was unable to share Christmas with their wider family.
52. Our advisor explained said there is always a potential risk in hospitals, when cohorting patients in a bay, that one of them develops a potentially infectious illness, which inadvertently puts the other patients at risk. However, at the time Mrs E was moved into the bay, none of the other patients in the bay had tested positive for Covid-19.
53. Our advisor explained that once the patient in the bay with Mrs E had tested positive for Covid-19, Mrs E would have been classed as a Covid-19 contact, meaning that there was a possibility that she might also test positive in the next fourteen days.
54. The Trust’s Infection Control Policy says at the time of Mrs E’s admission it advised not to move patients that tested Covid-19 positive but to enable them to remain in isolation in their bed space and for any patients in the bay to be tested daily and treated as a Covid-19 contact.
55. Based on the evidence we have seen it appears the Trust followed the guidelines in relation to infection control and minimising the risk of Covid-19, but unfortunately due to the nature of Covid-19, this could not mean that Mrs E would not contract Covid-19 as she was in a hospital with other patients during a time of pandemic.
56. The Trust explained that it had moved Mrs E as it felt this would be beneficial for her mental wellbeing and apologised if this caused her distress and anxiety.
57. We are satisfied the Trust acted in line with the guidelines to minimise the risk of Mrs E catching Covid-19, but unfortunately this could not prevent her from catching it in a public place. We will therefore take no further action on this complaint. We hope that our explanations have given him reassurance that the Trust followed the relevant guidelines.
58. We also hope that our investigation findings above for both Trusts and our adviser’s expertise have given Mr E reassurance that the Trusts followed the relevant guidelines and did not do anything wrong in relation to his wife’s care and treatment other than the treatment of her pressure sore, failing to reposition in line with expected guidance.