Poor pressure ulcer management and treatment
15. Ms C says she noted a small pinprick wound on her mother’s sacrum on 15 November 2021, which she reported at the time to nursing staff. She has concerns her mother’s wounds were not managed appropriately, and this caused the wound to become worse before it started healing. She says her mother’s skin was scarred as a result of the wound becoming worse during her admission.
16. NICE pressure ulcer guidelines say an individualised care plan should be created for all patients who have been assessed at high risk of developing a pressure ulcer.
17. The Trust’s pressure ulcer policy says a risk assessment should be completed for all patients within six hours of hospital admission. A Waterlow pressure ulcer risk assessment is a tool used to assess a patient’s risk of developing pressure ulcers. The policy says patients with a Waterlow score of ten or higher must then have further pressure ulcer risk assessments completed such as skin assessment and body map, pressure ulcer or moisture associated skin damage care plans, and the Integrated Pressure Ulcer Care Pathway (ICP). It adds patients at risk of pressure ulcers must have their skin assessed within six hours of admission and then at least three times a day, or more often if the risks increase.
18. The severity of pressure ulcers are assessed in six stages. Stage 1 is where there is visible skin redness which does not change when the skin is pressed. Stage 2 refers to partial thickness skin loss, stage 3 to full thickness skin loss, and stage 4 to full thickness tissue loss, with the other stages ‘unstageable’ (depth of damage unknown) and suspected deep tissue injury (depth unknown). The Trust’s policy also says all pressure ulcers graded at 2 or above, and any moisture associated skin damage, must be recorded as a clinical incident within 24 hours of discovery. Also, pressure ulcers that deteriorate must be reported as a clinical incident under the cause ‘pressure ulcer deteriorated’, and the ulcer assessed by a Tissue Viability Nurse. It adds a referral must be made to the tissue viability nurse for patients with pressure ulcers that do not heal as expected, and wounds must be managed through wound assessment charts.
19. Our nurse adviser says when Ms C reported the wound on 15 November her mother should have received an assessment by a nurse to acknowledge its presence and identify the cause of the skin damage. The medical team should be informed of the wound so they can examine it and consider care and treatment needs. A referral should be made to a tissue viability nurse to support appropriate wound care interventions and continued assessment of healing or deterioration of the wound. Tissue viability nurses can also support nurses with diagnosis of the wound type as either a pressure ulcer or moisture sore, so appropriate wound care can be given. Other appropriate interventions include a wound care plan and taking photographs of the wound as appropriate. All these actions would be in accordance with the Trust’s policy and NICE pressure ulcer guidelines.
20. Within Mrs F’s admissions documents, there is a Waterlow pressure ulcer risk assessment. Mrs F’s Waterlow score was calculated as ten (at risk of developing pressure ulcers). However, this document is undated, so we cannot be certain this risk assessment was done on the day of Mrs F’s admission. NICE pressure ulcer guidelines say a patient’s pressure ulcer assessment should be done within six hours of admission or transfer to or between wards. As the Waterlow assessment is undated and the time not noted, we cannot be certain Mrs F’s risk of pressure ulcers was assessed within six hours of her admission in line with NICE pressure ulcer guidelines. There are no indications of any ulcers at the time this assessment was done.
21. The Trust’s Pressure Ulcer Integrated Care Pathway (ICP) is a document used to ensure appropriate prevention and treatment of pressure ulcers. An ICP should be completed where a patient has a Waterlow score of ten or above, an existing pressure ulcer, a history of previous pressure ulcers or was considered at risk of developing pressure ulcers. The first ICP form we could see in the records is dated 16 November at 9.30pm, five days after Mrs F’s admission. On this form an initial body map was completed, and a skin tear on the sacrum was noted. However, the rest of the form, setting out initial actions to take such as reporting a clinical incident, wound assessment, starting a repositioning record, completing continence assessment – all relevant actions to complete in Mrs F’s case – are left blank. Our nurse adviser says they would expect to see interventions added to the ICP form setting out actions to take to promote healing of the wound. We cannot see evidence any such interventions were added once the wound was reported and assessed. We also note the ICP was not completed until over 24 hours after the pinprick wound was first reported to nursing staff.
22. We can see a body map was completed on 12 November, which sets out Mrs F had swelling on her left leg and knee. Additionally, a note added to the same page on 21 November recorded a pressure sore on Mrs F’s sacrum. While the Trust said in response to Ms C’s complaint that its records show Mrs F had the sore on 12 November and it was likely present on her admission, we do not take the same view. This is because it is clearly noted the sore on the sacrum was added to that body map on 21 November. We can see a note in the nursing records stating Ms C had raised concerns repositioning was not being done often enough, and that Mrs F had a pressure sore on her sacrum and the body map was updated. The body map dated 16 November records a ‘skin tear’ on the sacrum.
23. While body maps done during Mrs F’s admission show the position of the wounds on her sacrum, they are incomplete, with no details of interventions needed to promote healing of the wounds. There is also a lack of regular reassessments, which should have been done. When the pinprick wound was reported, a new Waterlow risk assessment should have been done, and a plan made for regular interventions to prevent the wound from getting worse. A Datix incident report (a system used by NHS Trusts to investigate all clinical incidents) should have been completed as well. The Trust said to Ms C when they met that an incident report would have been done when the skin tear was first noted. We could not see any evidence of an incident report being done in relation to this.
24. We can see Mrs F’s Waterlow score was reassessed on 16 November as 22, meaning she was at very high risk of developing pressure ulcers. However, there is no evidence of any plans made to treat the wound and prevent it getting worse, and we cannot see evidence of any incident reports completed during Mrs F’s admission.
25. The Trust says Mrs F was repositioned every two hours, with her skin checked and bowel charts completed. It adds a skin integrity assessment done on 12 November showed a small pressure ulcer on the sacrum, suggesting this was present on Mrs F’s admission. It thinks care was provided in line with its pressure ulcer policy and says a referral was made to a tissue viability nurse for advice. It says the tissue viability nurse advised staff to monitor Mrs F’s nutrition, apply barrier cream and dressings and use an autologic mattress (a mattress designed for use with patients with limited mobility and high risk of skin breakdown including pressure ulcers).
26. Ms C raised concerns on 15 November that nursing staff were not repositioning her mother as often as she needed this. She says it was only after she spoke with the ward manager on 24 November that her mother was moved to two hourly checks. This is evidenced in the healthcare records, when the ward manager noted Mrs F was to be monitored with strictly two hour checks and repositioning.
27. The evidence we have seen does not support the Trust’s assertion that repositioning was done every two hours. We have seen variations in the times between repositioning, and often gaps of four hours or longer between repositioning. From what the healthcare records show, regular two hourly repositioning was not started until 24 November. On that day, a new pressure ulcer was also noted on Mrs F’s buttock.
28. On 26 November the pressure ulcer on the sacrum was noted as grade 2, with a grade 1 pressure ulcer on the buttock. By 1 December the pressure ulcer on the sacrum was downgraded to grade 1, showing that it was starting to heal. By 4 December the pressure ulcer on the buttock had healed. The pressure ulcer on the sacrum was noted to have healed by the afternoon of 10 December 2021. A note on the ICP dated 17 December notes a scar from the pressure ulcer on the sacrum, which had now healed.
29. There are a number of inconsistencies in the healthcare records, and overall, completion of nursing documentation was poor. Mrs F’s risk of pressure ulcers, and management of the pinprick wound when reported, was not managed in line with NICE pressure ulcer guidelines and the Trust’s pressure ulcer policy. We think it likely this caused the ulcers to develop and then to become progressively worse due to poor pressure ulcer management. We have seen failings in this part of the complaint.
Barrier creams provided by Ms C were not used
30. Ms C complains ward staff did not use the barrier creams she provided to them on her mother’s admission. She says on 11 November she provided ward staff with her mother’s own barrier creams, which included Proshield foam and spray for cleaning the skin, and Proshield barrier cream. Proshield skincare products are specially designed for the prevention and management of incontinence-related skin issues and protects skin from moisture sores. Ms C says these were used at home by herself and district nurses, and they worked as her mother did not have a history of moisture or pressure sores despite her incontinence.
31. Ms C brought in further supplies of Proshield products on 20 November and handed them to the ward clerk. She says she also brought in incontinence pants, drinks and wipes which were all in a bag. The ward was closed due to a Covid outbreak at the time, so she was unable to visit her mother until 25 November. When she visited her mother again, she found the bag containing the products she had provided left unused in a cupboard.
32. NICE pressure ulcer guidelines say barrier preparations should be considered to prevent skin damaged in adults at high risk of developing a moisture lesion or incontinence-associated dermatitis. NICE patient experience guidelines say an individualised approach should be taken tailored to the patient’s needs and circumstances. The NMC code says nursing staff must listen to people and respond to their preferences and concerns.
33. We can see in the healthcare records references to cream applied to the skin, first noted on 14 November. There is no mention of what cream was used until 20 November, when staff noted ‘Derma’s Lolly pop’ was applied. Reference to application of creams was inconsistent, with no reference to cleansing or cream applied between 16 to 20 November. The first reference to the use of Proshield cream in the records is on 26 November, with a note this was to be used at every turn (during positioning checks). However, we can see the Trust’s own product (‘lolly stick’) continued to be used from 30 November and the next mention that Proshield was applied was on 3 December.
34. Our nurse adviser says it would have been appropriate for staff to use the skin care products provided by Ms C to help prevent deterioration of Mrs F’s skin. Nursing staff can incorporate the patient’s own creams in their care, unless there are any contraindications to doing so. If there are reasons why the patient’s own creams cannot be used, these should be explained to the patient and their families as appropriate. If staff had any uncertainty about using the patient’s own products, they should have sought advice from the tissue viability nurse.
35. Our nurse adviser explained ‘Derma’s lolly pop sticks’ are designed for use with incontinence-related skin problems to promote healing of wounds and would have been from the Trust’s own stock of these products. It may not have been unreasonable for staff to use this product, as they are designed for the care and treatment of skin wounds relating to incontinence. However, we could see no reasons recorded in the healthcare records to explain why these were used rather than Mrs F’s own creams which were provided during her admission by Ms C. Ms C says her mother’s skin did not start to improve until ward staff started regularly using the Proshield products.
36. We think, on balance, the failure to use Mrs F’s own creams, which were proven to be effective for her, contributed to the wounds becoming worse, leaving Mrs F with significant scarring as a result.
37. We think staff should have used Mrs F’s own barrier creams which were provided to ward staff by her daughter. That they did not start to use them until 15 days after they were provided was not in line with NICE patient experience guidelines and the NMC code. We find there were failings in care in relation to the application of barrier creams to Mrs F’s skin.
Poor hygiene and personal care (incontinence care)
38. Mrs F was doubly incontinent and needed support with her personal care, including cleaning after episodes of incontinence. Ms C says she found her mother left in a soddenly wet bed, in distress, on several occasions. She says her mother had called for help and nobody had come to assist her, and Ms C had to help her mother herself. She also says she found faecal matter on occasions on her mother’s skin and on bedding, and was told by ward staff this was just smearing.
39. The NICE patient experience guidelines says staff should ensure the patient’s personal needs (for example, relating to continence, personal hygiene and comfort) are regularly reviewed and addressed. The Trust’s policy says patients must have a holistic assessment that includes continence.
40. On 12 November, the day after Mrs F’s admission, a person centred care assessment was done. The section titled ‘elimination’, relating to bowel and bladder function, was left blank. And a section titled ‘continence assessment’ was also left blank, with all of the questions relating to urinary and bowel incontinence struck through. As Mrs F was doubly incontinent, these assessments should have been completed with her needs for support with continence management. A bowel chart was started on 13 November, although from what we have seen, this was not completed every day.
41. Ms C said on 29 November she found faeces on her mother’s bottom and legs and on bedding materials. She says she complained to ward staff and was told this was ‘only smearing’. She shared with us photographs which show solid faeces on bedding which suggest this was more than just smearing. Bowel charts completed on 26 and 27 November record Mrs F opened her bowels on those days with normal stools. Bowel charts completed on 28, 29 and 30 November show Mrs F did not have a bowel movement on those days. This suggests Mrs F was not properly cleaned after her last bowel movement on 27 November.
42. There are inconsistencies in the completion of bowel, incontinence and hygiene records, which are not in line with NMC standards on record-keeping and suggests the care provided was not in line with standards on incontinence and hygiene. We find failings in this aspect of care.
Cause of sepsis
43. Ms C has concerns that flavonifractor plautii, a bacteria found commonly in the gut, was isolated during blood tests to find the source of her mother’s sepsis in January 2022. She is understandably concerned that this bacteria could have entered her mother’s blood stream through faecal matter coming into contact with the open wound on her sacrum.
44. Our lead clinician says flavonifractor plautii is an organism that is usually found in the bowel, and is a very unusual cause of sepsis. A medical research paper published in 2018 stated only two people worldwide had been reported as having an infection from this bacteria, and in a second paper in 2022 the same researchers noted there had only been five reported cases of infection from it. Our lead clinician says we do not know much about how this bacteria causes infection or how those infections develop, but it seems to be associated with infections in people with impaired immune systems. Mrs F had an impaired immune system as she was taking methotrexate (an immune-suppressant) for rheumatoid disease. She also had a history of diverticular disease, a condition common in older people, in which small pouches form in the wall of the colon in the large bowel. On occasion these pouches can become inflamed or infected, although Ms C says at the time of her mother’s admissions her diverticular disease was stable.
45. Records show the wound on the sacrum seems to have healed by 10 December 2021. Blood tests were taken in hospital at that time to monitor infection and results suggested this was improving. This suggests the wound had healed and antibiotics provided for infection were working. Blood cultures taken during the admission showed no bacterial growth, and we can reassure Ms C they showed no evidence of the presence of flavonifractor plautii in the bloodstream. Following this, we can see no concerns were raised about infections in the area such as cellulitis (an infection of the skin and soft tissues underneath the skin).
46. Due to improvements in Mrs F’s infection markers, in our view the infection which caused sepsis would have started after 10 December 2021, when the wound on the sacrum had already healed. We also note flavonifractor plautii was not isolated during tests for the cause of Mrs F’s infection during her admission, which means it was not a factor in her illness at that time.
47. Our lead clinician explains diverticular disease is an issue that persists after it has been diagnosed, and this could have led to ‘seeding’ of the bacteria in the gut, leading to infection due to Mrs F’s weakened immune system. In our view the gap of six weeks between the sacral wound having healed and Mrs F being diagnosed with sepsis means it is very unlikely sepsis occurred as a result of the sacral wound.
48. In summary, we do not think it likely that the presence of flavonifractor plautii in the blood stream was caused by contact with contaminated faecal matter with the open wound on the sacrum. It is understandable, given Ms C’s experiences and the fact this bacteria is commonly found in the human gut, that she had this concern. We hope our explanations reassure Ms C that, even though we have found there were failings in maintaining her mother’s hygiene during incontinence, this did not directly cause her mother’s sepsis shortly afterwards.
Conclusion
49. We have seen failings in pressure ulcer management and treatment, delays and inconsistences in the use of the patient’s own barrier cream products, and poor hygiene and personal care when managing Mrs F’s incontinence. We think these failings contributed to the wounds needlessly becoming worse, and caused pain, distress and indignity to Mrs F. Witnessing the events, which continued despite raising concerns with ward staff, caused distress to Ms C. As a result, we partly uphold Ms C’s complaint. We set out below the recommendations we make to the Trust to put things right.