19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indication that something has gone wrong.
COVID-19
20. Mr W said the Trust admitted his mother to a ward where patients were infected with COVID-19 and contracted COVID-19 as a result. He said staff put Mrs W at risk of COVID-19 unnecessarily.
21. The Trust said during Mrs W’s admission, staff carried out routine COVID-19 testing twice a week as part of its infection control plan. The Trust acknowledged that on 4 April 2022 as part of its surveillance and screening process, Mrs W tested positive for COVID-19. The Trust said it worked very hard to eliminate the risk of patients getting COVID-19 whilst in hospital through adhering to stringent infection prevention and control policies.
22. Although the Trust did not comment on if it had placed Mrs W on a ward with COVID-19 patients, it apologised that Mrs W caught COVID-19 while in hospital.
23. At the time of Mrs W’s hospital admission, the Trust had a standard operating procedure for COVID-19 infection prevention and control. Mrs W’s admission was in March 2022, so COVID-19 prevention policies were still in use, although they had been relaxed.
24. The Trust’s operating procedure specifies various pathways that a patient should be under during their time in hospital. In Mrs W’s case, the records show she was on a green pathway, which is defined as any care facility for clinically assessed individuals with no COVID-19 symptoms and no known recent COVID-19 contact.
25. The Trust’s operating procedure was also in line with national guidance that was in place at the time, which stated that organisations may utilise care pathways to enable early recognition of patients with any respiratory infections.
26. The guidance adds that organisations should, where available, include testing as part of their IPC risk mitigation strategy when there are more patients getting infected.at times of increased infection prevalence.
27. Mrs W’s records show once she had been assessed in the Emergency Department, staff transferred her to Ward T10, an elderly care ward. Staff screened Mrs W for COVID-19 upon admission to the ward in line with its own internal framework and continued to regularly test her throughout her admission.
28. Mr W has said the Trust admitted his mother to the ward with other patients who were infected with COVID-19, which was not a suitable environment for her and caused her to contract COVID-19. He said his mother had told him that she had noticed a lot of activity in the days before she caught COVID-19 and staff were wearing more Personal Protective Equipment (PPE), which led her to believe there may have been a COVID-19 outbreak on the ward.
29. We have not seen any evidence from the records that shows the Trust knowingly placed Mrs W in a ward that contained patients with COVID-19. The evidence we have seen shows that the Trust was adhering to strict infection prevention and control measures to try and minimise the risk of patients getting COVID-19. The records also show the Trust was making plans for Mrs W to receive an additional booster vaccine before she tested positive for COVID-19. This again shows that staff were trying to reduce the likelihood of Mrs W catching COVID-19.
30. Unfortunately, in a hospital environment, it is not always possible to eliminate the risk of infection. Once Mrs W had tested positive on 4 April 2022, the Trust acted quickly to transfer her to Ward T8, an infection control ward, and staff placed her in a side room to receive treatment and monitoring for any signs of a clinical deterioration.
31. These actions were again in line with the national guidelines, which say:
‘in the hospital setting the patient should, wherever possible, be placed in a single room, ideally with en-suite facilities’.
32. Mrs W’s symptoms worsened in the following days, and the Trust transferred her to the Intensive Care Unit (ICU) as her oxygen levels had dropped significantly. Mrs W continued to received treatment in the ICU for five days until she stabilised, and the Trust transferred her to a step-down ward.
33. We recognise Mr W is concerned staff did not do enough to prevent his mother from catching COVID-19 and put her health at risk. We appreciate Mr W was very worried about his mother’s health, given her age and comorbidities, and wanted to ensure the Trust had done everything it could to protect her from COVID-19.
34. We hope Mr W is reassured that from the evidence we have seen, the Trust was taking preventative measures to reduce the risk of Mrs W catching COVID-19. Although we are sorry to hear that Mrs W caught COVID-19 in hospital, we consider the Trust’s actions were in line with standards and guidelines.
Communication
35. Mr W said the Trust failed to communicate effectively with him on his mother’s condition throughout her admission. Mr W also said the Trust failed to notify him in a timely manner that his mother had tested positive for COVID-19.
36. The Trust apologised that Mr W felt the communication with the ward had not been the standard he expected. It said due to visiting restrictions in response to COVID-19, the Trust was receiving a larger volume of calls. It said it recognised and acknowledged that relatives and family care givers have had some difficulty receiving regular telephone communication with the nursing, medical and wider multidisciplinary team over this period.
37. The Trust said as part of improving its service, it has made several changes to the way in which it communicates with relatives. It said it had purchased two new mobile devices which are always carried by the nurse in charge, so that access to the ward teams is more streamlined.
38. The Trust said despite these additions, it recognises that relatives may not always receive a response straight away due to the staff being involved in direct clinical care to patients. It has therefore increased its family liaison team who now contact relatives when a patient transfers to the T10 ward, and they provide ongoing support to agree regular updates and visiting times with family.
39. GMC Good medical practice guidance that was in place at the time of Mrs W’s admission says ‘you must be considerate to those close to the patient and responsive in giving them information and support’.
40. Mrs W’s records show Mr W was contacting the ward on a regular basis for updates on his mother’s condition throughout her admission. Staff were not always able to answer the phone at the time Mr W called, although they made consistent efforts to contact him back when they were able to.
41. Mr W also said the Trust failed to contact him to let him know his mother had contracted COVID-19 and he only found out once staff had moved her to another ward.
42. The Trust said as part of its Duty of Candour it informed Mr W on 5 April 2022 that his mother had tested positive for COVID-19 the day before. It said staff had further telephone conversations with Mr W on 7 and 8 April to discuss her symptoms and clinical deterioration.
43. We have reviewed the records of Mrs W’s admission, and these support the Trust’s account of the frequency of its communication. We understand Mr W was very anxious about his mother’s health, especially once she tested positive for COVID-19. Based on the evidence we have seen, the Trust showed consideration for Mr W’s requests for updates and was responsive to these.
44. We understand the situation was difficult for Mr W, he was reluctant to visit his mother as he was looking after his father at home who was also unwell. Therefore, telephone updates became even more important for Mr W. From the evidence we have seen, staff took this into account but had to prioritise clinical care.
45. We have not seen any indications the Trust did anything wrong in how it communicated with Mr W. We also acknowledge the Trust has made significant improvements to its service in how it communicates with patients’ family members.
Leg ulcers
46. Mr W said the Trust failed to effectively treat his mother’s leg ulcers during her time in hospital and allowed them to deteriorate significantly. He said he had to transfer his mother to a private hospital where her symptoms improved.
47. The Trust said following Mrs W’s admission on 13 March 2022, staff regularly cleaned and dressed her ulcers and treated her with antibiotics. The Trust said Mrs W also had regular reviews with tissue viability nurses and by the time of her discharge, the ulcers had improved.
48. The Trust said Mrs W then had a telephone appointment with the vascular team on 30 April 2022 where she agreed that conservative rather than surgical management of her ulcers would be in her best interests, due to her complex medical history.
49. Mrs W was then admitted again on 17 May 2022. The Trust said the tissue viability team had expressed concern at the extent to which the ulcers had deteriorated. It said it had spoken to Islington district nursing team who had raised concerns that despite their efforts to help manage Mrs W’s ulcers in the community, Mr W had disagreed with their advice, such as more frequent dressing changes, compression bandaging and elevation.
50. The records of Mrs W’s admission confirm she had chronic lower left leg ulceration on a background of chronic venous insufficiency (a problem with the flow of blood from the veins of the legs back to the heart).
51. Staff took photographs of Mrs W’s leg on admission, which showed numerous gaiter ulcers (gaiter describes the area a few inches below the knee to the ankle), which were described as sloughy. Slough is de-vitalised tissue formed when dead cells and/or bacteria accumulate in wounds.
52. Guidance on the management of chronic venous leg ulcers states that:
‘leg ulcers are frequently painful, particularly if they have an arterial component or are associated with cellulitis or deep infection, and strong analgesics are likely to be required…
In patients with chronic venous leg ulcers, systemic antibiotics should not be used unless there is evidence of clinical infection…bacteriological swabs should only be taken when there is clinical evidence of infection’.
53. Additionally, the NMC Code explains that nursing staff should,
• ‘respect the skills, expertise and contributions of your colleagues, referring matters to them when appropriate • make a timely referral to another practitioner when any action, care or treatment is required • ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence’.
54. On Mrs W’s admission on 13 March 2022, staff took swabs from her leg ulcers as they were concerned about a possible infection. The swabs confirmed that the ulcers were infected, and additional scans indicated it was likely that Mrs W had osteomyelitis (inflammation or swelling that occurs in the bone, often because of an infection that has spread). Staff then prescribed regular analgesia to Mrs W. Our nursing adviser said these actions were in line with SIGN guidelines on management of venous leg ulcers.
55. On the same day, staff requested a review from a Tissue Viability Nurse (TVN) and ward staff got advice on dressing Mrs W’s leg ulcers before any dressing changes took place. The TVN review took place on 16 March and recommended dressing changes on alternate days. These actions were in line with the NMC Code’s instructions.
56. Our nursing adviser said the records consistently demonstrate that nursing staff followed the TVN advice on the frequency of the dressing changes. Despite this, on 10 April, the records show Mrs W’s ulcers were ‘looking worse and more sloughy than when it was last reviewed’.
57. Our adviser said nursing staff immediately sought further input from the TVN which resulted in a change to Mrs W’s treatment plan. These actions were again in line with the NMC Code. The evidence shows Mrs W’s leg ulcers were beginning to improve by the time she was discharged.
58. On Mrs W’s discharge from hospital, the Trust recommended a referral to a district nursing team for ongoing leg ulcer management due to the decline in Mrs W’s mobility. Our nursing adviser said this was appropriate to ensure the leg ulcer management continued with a structured approach once Mrs W was no longer in hospital.
59. We recognise that during Mrs W’s time at home before she was readmitted to hospital on 17 May 2022, her leg ulcers deteriorated again. We acknowledge Mr W’s view that this was due to the Trust’s treatment of the ulcers during her time in hospital.
60. Based on the evidence we have seen, the Trust’s management and treatment of Mrs W’s leg ulcers was correct in line with relevant standards and guidelines. We are unable to comment on the actions of the district nursing team as Mr W has not complained to the relevant organisation.
61. Once Mrs W returned to the Trust on 17 May and reported severe pain to her ulcerated left leg, the Trust prescribed and administered stronger analgesia than the codeine and paracetamol that she had previously been taking. The TVN management plan referred to analgesics that are effective against nerve pain.
62. Mrs W’s course of treatment during this second admission followed a similar approach to her first admission, with regular dressing changes, a wound management plan and weekly TVN reviews. Our nursing adviser said photographs the day before her discharge on 31 May show that there had been a slight improvement since admission, before Mr W decided to transfer his mother to a private facility instead for treatment.
63. We recognise Mr W was alarmed at the deterioration in his mother’s leg ulcers and thought the Trust was responsible for this. We have considered all the available evidence and have seen no indications the Trust did anything wrong in how it treated Mrs W’s ulcers.
Conclusion
64. We understand this was a challenging time for Mrs W with two significant hospital admissions and testing positive for COVID-19 during the first admission. We also appreciate Mr W found the events distressing.
65. We hope our decision will reassure Mr W that the Trust treated his mother correctly in line with relevant standards and guidelines.