Delayed diagnosis 20. Miss A says there was a delay in diagnosing her sister with a fractured pelvis between 1 and 6 April 2023. She says it ignored her requests for an X-ray during this period on several occasions.
21. The BGS guidance explains people who suffer a fall should have an assessment in the ED which includes an examination for acute injuries, and the results of these examinations determine what types of tests should be carried out. It also outlines that older people who experience major trauma may not always be easily identified, as they can experience trauma because of ‘low energy transfer’. For this reason, clinicians should:
• Carry out a trauma primary and secondary survey for every older patient who has a fall (a primary survey is a full body assessment of the patient and a secondary survey is a detailed look at all parts of the body to establish what happened after a trauma) • Have a low threshold for whole body CT scanning, particularly for any patient with chest discomfort following a fall • Use a trauma record sheet for every older faller, even if no obvious signs of injury, to force a trauma secondary survey • Request X-rays on patients who have suffered an acute injury following the initial assessment to establish the extent of the injury • Carry out a further review of a patient’s condition within three to four hours of the admission, by reviewing their gait and balance disturbance (walking ability) through a review of their current level of mobility.
22. The BGS guidance goes onto explains clinicians should also recognise if a patient is unable to provide details themselves at the time of their admission due to confusion, then further information should be sought from another source (healthcare partners, family) to determine the accuracy of the presenting condition and history in the ED.
23. The clinical records show during the ED admission on 1 April, the Trust examined Mrs C and created a treatment plan. The Trust felt she had suffered a fractured wrist following a fall at home. We cannot see at this stage the Trust carried out a full primary survey by assessing all of Mrs C’s body or completed a secondary survey on Mrs C to establish the full extent of her injuries following her fall at home. This is contrary to the BGS guidance on completing a primary and secondary survey, and we consider this is a failing.
24. The records also show Mrs C was confused at the time of the ED assessment. Our geriatrician adviser explains it was therefore even more important for the Trust to carry out a detailed examination to work out the extent of Mrs C’s injuries following her fall. We can see no evidence the Trust sought further information to determine the accuracy of the history given. This is contrary to the BGS guidance on seeking further information from another source during the ED assessment, and we consider this is a failing.
25. There is no evidence to suggest the Trust carried out an assessment of Mrs C’s gait or balance within three to four hours of her initial ED assessment, as outlined by the BGS guidance. The first occasion we can see the Trust assessed Mrs C’s gait was on 2 April, when it recorded that Mrs C was normally able to mobilise with frame, but we cannot see the Trust completed a full review of her walking ability until 11 April. This is contrary to the BGS guidance on completing a gait assessment within three to four hours of the admission, and we consider this is a failing.
26. The records show the clinicians first suspected Mrs C had a pelvic fracture during a review on 4 April, but the records do not provide any justification or explanation as to why this was suspected. On 4 April the Trust requested a pelvic X-ray for the same day, but this was not completed. It was requested again on 5 April. The results of the X-ray were reported on 6 April, that Mrs C had a pelvic fracture. This is contrary to the BGS guidance on requesting an X-ray to establish the extent of the injury suffered, and we consider this is a failing.
27. The Trust has acknowledged in its final response letter that there was a delay in the diagnosis and says it cannot offer any specific comments as to why there was no suspicion that Mrs C suffered a pelvic fracture sooner than it did. Overall we consider there was a delay in the Trust diagnosing Mrs C with a pelvic fracture between 1 and 6 April and our clinical advice supports this view.
28. Miss A explained to us that after receiving the final response, she was left unsure about what exactly happened during her sister’s admission. We understand why this was distressing and has been an ongoing concern for her. We hope our findings in respect of this provide her with a further explanation as to what happened during her sister’s admission to the ED.
29. As we have identified a failing in respect of the time taken to diagnose Mrs C with a pelvic fracture, we will now consider whether there is any link between this and Miss A’s claimed impact. She says her sister’s fractured pelvis meant she was in an extreme amount of pain during the admission, which she never fully recovered from until her death in August 2023. We are sorry to hear Miss A’s concerns that her sister was left in pain.
30. We have reviewed the clinical records and can see between her admission on 1 April and her discharge on 14 April the Trust completed regular observations, several times a day on Mrs C’s overall condition, including her pain. Throughout this period the Trust asked her if she was in any pain at any point, and on each occasion, Mrs C explained she was not suffering from any pain.
31. We have identified one occasion on 11 April during a physiotherapy assessment that Mrs C explained she was in pain during the assessment, and the Trust provided her with pain relief for this. This appears to have resolved during the next session and she did not report to be in pain again for the rest of her admission. Reassuringly we have seen no evidence which shows Mrs C was suffering with an extreme amount of pain at any point during the admission, as Miss A says.
32. We asked our geriatrician adviser if the delay in diagnosing the pelvic fracture had any impact on Mrs C. They have explained Mrs C’s deteriorating condition during her admission was likely caused by a combination of factors, including her fall at home, the resulting long lie on the floor, the subsequent fractures of her wrist and pelvis, her overall confusion, her diagnosis of COVID-19 and her chest infections. They say it is therefore difficult to say to what extent the delay in diagnosis of the pelvic fracture specifically contributed to her overall deterioration in health.
33. Taking this into consideration, on balance we therefore think it is more likely than not the delay in diagnosing Mrs C’s pelvic fracture contributed to her condition deteriorating, but we cannot ever say to what extent this contributed.
34. We understand how important this issue is for Miss A and how worrying it has been for her to feel her sister was left in pain for a substantial period. Reassuringly we consider there is no evidence that Mrs C was in significant pain during her admission at any point. We do consider it is likely the delay contributed to her deteriorating condition, but we will never be able to say with certainty to what extent this contributed. Overall we are unable to find any link between the failings we have found, and Miss A’s claimed injustice.
35. We understand the knowledge that there were shortfalls in the care and treatment provided to her sister is likely to cause Mrs C distress. We can see in the final response letter the Trust has acknowledged there may have been a delay in diagnosing Mrs C’s fracture, but it says it cannot provide any reason why a pelvic fracture was not suspected sooner. While we can see the Trust has recognised there may have been a delay, we do not think the Trust has taken appropriate action to remedy the failings we have identified and the subsequent impact this had on Mrs C and her sister.
36. We therefore recommend the Trust apologises to Miss A for the failings we have identified and acknowledges the subsequent impact this had on her and on Mrs C. We also recommend the Trust creates an action plan to show what it plans on doing to prevent the same thing from happening again. We discuss this later in our report.
Skin care 37. Miss A says the Trust failed to provide appropriate skin care between 1 and 14 April 2023.
38. The NICE CG179 guidance explains all patients are potentially at risk of developing a pressure ulcer. However, they are more likely to occur in people who are seriously ill, have a neurological condition, impaired mobility, impaired nutrition, or poor posture or a deformity. It recommends healthcare practitioners should carry out an assessment on a patient’s skin of their risk of developing a pressure ulcer within six hours of admission. They should also use a validated scale to support the clinical judgement of the skin damage (such as a Waterlow test) to assess pressure ulcer risk. Similarly the Trust’s policy also states all patients should have a risk assessment of their skin within six hours of admission. The score from the Waterlow test helps clinicians to determine how at risk a person is of skin damage.
39. The NICE CG179 guidance also says if the patient is unable to reposition themselves, healthcare practitioners should offer help to do so, using appropriate equipment if needed, and document the frequency of repositioning required. For further prevention and management, they should also use pressure redistributing devices (such as mattresses) and barrier cream if necessary.
40. The Trust’s policy outlines that any patient with a deep tissue injury should be referred to the TVN service. It says the deep tissue injury should be photographed to evidence development. It says that patients who have a deep tissue injury should be considered for a pressure redistributing (dynamic) mattress.
41. The clinical records outline that Mrs C arrived at the ED at 7.01pm on 1 April. During the assessment within the ED the Trust carried out a pressure area management risk assessment on Mrs C at 10.30pm in which it states her skin was ‘red and blanching’. Within this form the Trust documented that Mrs C was not at risk of developing a pressure sore.
42. Our nursing adviser explains at the time of admission Mrs C was seriously ill, had impaired mobility and impaired nutrition. They explain as Mrs C had suffered a long lie at home for an unknown duration, they consider she was at risk of developing a pressure sore, as outlined by the definition given under the NICE CG179 guidance. Our nursing adviser explains given her condition it would have been helpful at this time for the Trust to complete an additional risk assessment such as a Waterlow assessment to further assess her risk of skin damage.
43. We can see no evidence to show the Trust completed a Waterlow assessment within six hours of the admission as recommended by the NICE CG179 guidance and the Trust’s own guidance. We find this was first done on 2 April at 2.11pm, 19 hours after the time of the admission. We consider there was a delay of 13 hours in the Trust completing a Waterlow risk assessment. This is contrary to both the NICE CG179 guidance and the Trust’s guidance on completing the assessment within six hours, and we consider this is a failing.
44. We can see between her admission onto the ward on 2 April until her discharge on 14 April the Trust reviewed Mrs C’s skin on several occasions, every day. Mrs C was noted to largely have category one pressure damage during this period (the least severe type of pressure damage) with red or purple blanching skin. The assessments show there was no evidence of significant pressure damage during this period.
45. The Trust identified she needed help repositioning and created a repositioning schedule to move her on average every two to four hours. The records show the Trust kept to this schedule between this period. We can see the Trust administered barrier cream to prevent her skin from breaking down further and provided her with dressings during this period. Our nursing adviser explains in general the Trust provided appropriate care and treatment with regards to the prevention of breakdown and management of Mrs C’s skin during this period. This is in line with the NICE CG179 guidance and our clinical advice supports this view.
46. During this period, we have identified one occasion when skin care fell short of what was expected.
47. The clinical records show on 4 April at 3.30pm the Trust first identified Mrs C potentially had a deep tissue injury. The Trust photographed the deep tissue injury but there is no evidence to suggest the Trust requested a referral at this stage to the TVN team or requested a specialist pressure relieving mattress. The first time we can see a referral for a specialist mattress for Mrs C was on 6 April at 10.29am. The Trust also referred Mrs C to a TVN at this time. This is contrary to the Trust’s guidance on providing pressure relieving equipment, and we consider this is a failure.
48. Overall we consider the Trust has largely treated Mrs C’s skin in line with the NICE CG179 and Trust guidance. We have identified there was an overall delay of 13 hours in the Trust completing its first Waterlow risk assessment on Mrs C, and a delay between 4 and 6 April in the Trust providing appropriate a pressure relieving mattress for her.
49. As we have identified failings, we will now consider whether there is any link between these and Miss A’s claimed injustice. She says poor skin care contributed to her sister’s condition deteriorating and caused her sister to develop a pressure sore which she eventually died from. Miss A explains how distressing it was to see her sister’s condition deteriorating, and we are truly sorry to hear how much of an impact this issue continues to have on her.
50. In respect of the delay we have identified in the Trust completing a Waterlow assessment, we can see on Mrs C’s first Waterlow assessment on 2 April, her score was 17. This meant she was at high risk of developing a pressure ulcer (a score of between 15 and 19 is deemed as high risk). We can see during this time Mrs C was already on bed rest, had a repositioning schedule in place and had been given pressure relieving equipment for her heels.
51. Our nursing adviser explains other than this delay, the Trust has treated Miss A appropriately at this time in line with the NICE CG179 guidance. They consider there is no evidence Mrs C had any significant pressure damage on her skin at this time. Taking this into consideration, we are satisfied there is no evidence to suggest this delay caused the breakdown of Mrs C’s skin, as Miss A claims.
52. We have also considered the delay in providing the appropriate pressure relieving mattress between 4 and 6 April. Pressure relieving equipment works by redistributing the pressure on a person’s skin for comfort and to prevent further breakdown.
53. We asked our nursing adviser what the impact would have been, of Mrs C being without this type of mattress between 4 and 6 April. They consider this failing would have resulted in Mrs C experiencing discomfort from the deep tissue injury during for longer than was necessary between 4 and 6 April.
54. Largely we can see the Trust provided sufficient skin care to Mrs C, it managed her skin effectively and provided treatment to prevent the skin breaking down. We have seen no evidence to suggest the failure to provide an appropriate pressure relieving mattress to Mrs C caused her skin to significantly break down, as Miss A is claiming. On balance we consider it is likely this failing caused Mrs C discomfort between 4 and 6 April.
55. We acknowledge the knowledge of this failing and the impact on Mrs C is likely to cause Miss A distress. In its response the Trust has apologised Mrs C developed a deep tissue injury whilst in hospital. We are pleased to see the Trust has taken this issue seriously. It has provided feedback to the staff involved to discuss pressure area care at the ward daily huddles, to highlight the importance of identifying and categorising sores and implementing the appropriate care to all patients.
56. We have considered the Principles, specifically under the heading ‘putting things right’, to determine whether the action taken by the Trust in relation to this issue is sufficient. The Principles outline a wide range of remedies available to a complaint, including an apology, an explanation of what happened, and action to prevent the same thing from happening again.
57. We make recommendations to remedy the impact we find has been directly caused by any failing we identify. We have seen no evidence to suggest Miss A’s claimed impact occurred because of the failings in skin care we have identified. We have seen no evidence to raise any wider concern about the standard of care provided by the Trust during Mrs C’s admission.
58. We are satisfied the Trust has taken the experience Miss A had at the Trust seriously and apologised for this. It has also taken action to prevent this from happening again in the future. This is sufficient and in line with the Principles. For this reason, we do not consider service improvements are required in relation to the failings we have identified in relation to the Trust’s skin care.