Walsall Healthcare NHS Trust

7. Mrs A complains about the care and treatment provided by the Trust to her mother, Mrs D. She says the Trust failed to provide her mother with the appropriate care and treatment for her breast abscess from the date she first attended the Trust on 7 December 2022 until the date she died on 3 May 2023.

8. Mrs A says the Trust missed the opportunity to treat her mother’s abscess sooner. She says the Trust missed the opportunity to act earlier to prevent her abscess from developing into a sepsis infection. She says her mother may not have died if the Trust had provided her with appropriate care and treatment from the outset. Mrs A says the death of her mother has caused her a great deal of distress.

9. Mrs A would like the Trust to acknowledge the failings and apologise. She would also like the Trust to put in place significant service improvements.

10. Mrs D had a history of diabetes, heart failure, ischaemic heart disease (narrowing of the arteries), chronic kidney disease, gall stone pancreatitis (inflammation of the pancreas due to blockages caused by gall stones) and cellulitis (a bacterial infection of the skin and the tissue beneath the skin). She was under the care of the Trust’s breast clinic for a haematoma (an abnormal pooling of blood in the body under the skin that results from a broken or ruptured blood vessel) that had developed on her breast in 2017. Mrs D experienced swelling from the haematoma which the Trust treated with drainage and antibiotic medication.

11. Mrs D’s haematoma did not improve despite the Trust’s attempts at treatment and when she attended hospital on 7 December 2022 the haematoma had started to leak fluid. Mrs D was assessed by the Trust and her treatment options discussed in a multidisciplinary team (MDT) meeting. As the previous attempts at treatment had not resulted in any improvement, the MDT decided that a definitive surgical treatment was required.

12. Whilst the Trust were considering Mrs D’s surgery options she was admitted to hospital on 26 February 2023 suffering with abdominal and chest pain. The Trust provided treatment and discharged her from hospital on 21 March 2023. Mrs D was admitted to hospital again on 30 April 2023 as the haematoma on her breast had developed into an abscess and showed signs of infection. Mrs D became unresponsive whilst in hospital and sadly died on 3 May 2023.

16. Mrs A says the Trust failed to provide her mother with the appropriate treatment for her breast abscess from 7 December 2022 to 3 May 2023. She says the Trust should have provided treatment sooner and if it had her mother’s abscess would not have become infected and she would not have died.

17. The GMC guidance states:

‘You must provide a good standard of care. If you assess, diagnose or treat patients, you must:

• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient

• promptly provide or arrange suitable advice, investigations or treatment where necessary

• refer a patient to another practitioner when this serves the patient’s needs.

In providing clinical care you must:

• provide effective treatments based on the best available evidence

• consult colleagues where appropriate.’

18. Mrs D’s breast haematoma had been present since 2017 and the Trust had previously provided treatment to drain the fluid from the haematoma and had provided antibiotic medication to reduce the risk of infection.

19. The records indicate Mrs D attended the Trust on 7 December 2022 and was reviewed by a surgeon who noted her haematoma had started to leak serosanguinous fluid (a fluid secreted from a wound in response to tissue damage as part of the wound healing process). The Trust held an MDT meeting to discuss her treatment options and recommended a partial mastectomy (surgery to remove the haematoma along with some of the surrounding breast tissue).

20. The MDT referred Mrs D to the anaesthetic department for pre-operative assessments. Our surgeon adviser said the records indicate the Trust were aware Mrs D had other significant health concerns which would increase the risk of her surgery and the MDT recommendation on 7 December 2022 was for a high-risk anaesthetic assessment. The purpose of the assessment was to determine the safest anaesthetic to use for her surgery and whether it should be carried out under general anaesthetic (sedating the patient) or local anaesthetic (numbing an area of the body whilst the patient remains awake.)

21. The records indicate Mrs D attended the Trust for an initial pre-operative assessment on 19 December 2022. She then attended the Trust for a high-risk anaesthetic assessment on 18 January 2023. The anaesthetist who performed the high-risk anaesthetic assessment decided due to Mrs D’s heart failure and frailty the safest approach was for her surgery to be carried out under a local anaesthetic.

22. Following the high-risk anaesthetic review of 18 January 2023 the records indicate the Trust sought an additional anaesthetic opinion about the possibility of performing her surgery under a regional block (a specific anaesthetic technique that inhibits nerve transmission to certain area of the body).

23. The records indicate Mrs D became unwell while the Trust were still investigating the most appropriate anaesthetic for her surgery. She was admitted to hospital on 26 February 2023 due to a deterioration in her condition, unrelated to her haematoma, and the Trust treated her for cholangitis (inflammation of the bile duct) and associated biliary sepsis (an infection of the biliary system), gallstones and pancreatitis.

24. Our surgeon, anaesthetist and physician advisers agree there was a window of opportunity for the surgery between her initial attendance on 7 December 2022 and her admission to hospital on 26 February 2023. Our advisers agree if the surgery had been performed during this period it is possible the haematoma could have been removed before it developed into an abscess. However our anaesthetist adviser said the surgery posed a risk to Mrs D and it is not possible to say for certain what the outcome of the surgery would have been if it had been attempted during this period.

25. Our physician adviser said there is no evidence in the records to indicate the haematoma was life threatening at this time or required urgent surgery to remove it. The records indicate the haematoma did not change between 7 December 2022 and 26 February 2023 and the records from Mrs D’s admission on 26 February 2023 indicate that, although it was still discharging serosanguinous fluid, it had not worsened, developed into an abscess or become infected.

26. Our anaesthetist adviser said her haematoma had been an ongoing but stable clinical problem since 2017 and Mrs D had several other serious health concerns which increased her risk of surgery which had to be fully considered and assessed by the Trust before deciding on the appropriate approach to take. Partial mastectomy is a significant surgical procedure and the records indicate the Trust wanted to explore all surgical options before proceeding with the surgery. Our physician adviser said there is no evidence in the records to indicate the surgery to remove her haematoma was clinically urgent up to this point.

27. We carefully considered the advice from our advisers. We do not consider it a failing that the Trust did not perform the surgery between 7 December 2022 and 26 February 2023 despite there being a window of opportunity to do so. The haematoma had been present for several years prior to Mrs D’s attendance on 7 December 2022 and there is no indication in the records up to 26 February 2023 that the haematoma required urgent surgery. The records indicate the haematoma was not life threatening at this time and there is no evidence of it worsening or becoming infected during this period.

28. Following Mrs D’s admission to hospital on 26 February 2023 the records indicate the focus of the Trust’s treatment was her cholangitis and associated biliary sepsis, gallstones and pancreatitis which was a life threatening combination of conditions for her at this time. Whilst providing this treatment the Trust continued to monitor her haematoma and the records note it did not change during this admission. The Trust also performed an echocardiogram (a procedure that uses high frequency sound waves to view the heart’s chambers, valves, walls and blood vessels) as part of her pre-operative assessments.

29. Our physician adviser said it is clear the Trust were still planning for surgery during this admission. However there is no indication in the records the surgery could have been provided at this time as Mrs D was very unwell due to her other significant health conditions.

30. The records indicate once her condition had stabilised the Trust discharged Mrs D from hospital on 21 March 2023. Following her discharge the Trust decided not to proceed immediately with her surgery as she required a period of recouperation before she could be considered well enough.

31. Our surgeon, anaesthetist and physician advisers agreed Mrs D’s admission with cholangitis and associated biliary sepsis, gallstones and pancreatitis posed an immediate risk to her life and it was therefore appropriate for the Trust to recommend a period to allow her to fully recover before arranging her surgery. Our physician adviser said a full recovery would be required before the focus of treatment could be moved back to her haematoma.

32. The records indicate the district nurse called the Trust on 28 April 2023 as Mrs D’s haematoma had deteriorated. Mrs D was admitted to hospital on 30 April 2023 due to a foul smelling purulent discharge (thick fluid from a wound that is a sign of infection) from an abscess associated with an area of broken-down, necrotic skin (tissue that has died) on the site of her breast haematoma. The Trust performed a series of blood tests which identified raised inflammatory markers and prescribed antibiotic medication for sepsis infection.

Mrs D did not recover from her infection and sadly died on 3 May 2023.

33. Our physician adviser said the records indicate prior to this presentation to hospital, there was no evidence of an abscess or an infection, only a non-resolving large haematoma. Our physician adviser said such a deterioration can happen relatively quickly and there is no evidence in the records to indicate this development at this time could have been foreseen. Our anaesthetist and physician advisers agree there was no opportunity to consider surgery when Mrs D was admitted on 30 April 2023 as she was not well enough to withstand the procedure at this time and the focus of her treatment was on her sepsis infection.

34. The NICE guidance on sepsis recommends treatment with antibiotics. The GMC guidance says suitable treatment should be provided promptly and effectively. The records indicate the Trust acted in line with the NICE guidance on sepsis and put in place a treatment plan of antibiotic medication very quickly after Mrs D’s admission. However once the plan was put in place it seems the Trust did not act in line with the GMC guidance to ensure the antibiotic medication was provided appropriately. We think this is a failing.

35. The medication charts in the records indicate the Trust provided Mrs D with an initial dose of antibiotic medication at 10.00pm, shortly after she was transferred from A&E to the medical ward. However the medication charts in the records indicate the Trust missed two doses (the 6pm to 8pm dose on 1 and 2 May 2023) and delayed one dose (the 10pm to 12am dose on 2 May 2023 which was not given until 1.20am on 3 May 2023) of antibiotic medication due to difficulties it experienced with Mrs D’s cannula. The medication charts in the records also provide no information to confirm whether antibiotic medication was administered to Mrs D on 3 May 2023.

36. Our physician adviser said it is not possible to conclude that Mrs D died as a result of the failings in the Trust’s management of her antibiotic medication. Our physician adviser said it is not possible to say whether the antibiotic medication would have prevented Mrs D’s condition from deteriorating even if it had been administered appropriately due to her very poorly condition at this time. However it would have been in line with the NICE guidance on sepsis and the GMC guidance to ensure the correct doses of antibiotic medication were given at the correct times without any omissions or delays.

37. We found no evidence to indicate the Trust’s failure to manage Mrs D’s antibiotic medication led to her death. It is clear Mrs D was at serious risk of deterioration due to the severity of her illness and comorbidities. However it is a significant failing and a missed opportunity to ensure her treatment was provided appropriately.

1. We partly uphold Mrs A’s complaint. We acknowledge how upsetting these events were and that they continue to cause her considerable distress.

2. We found there was a window of opportunity to perform the partial mastectomy surgery to try and resolve Mrs D’s chronic breast haematoma between 7 December 2022 when she first attended the Trust and 26 February 2023 when she was admitted to hospital due to an unrelated condition.

3. We do not consider it a failing on the part of the Trust that the surgery was not performed during this period as the haematoma had been present for several years, did not deteriorate during this period and we found no evidence to indicate once the decision to perform the surgery was made by the Trust, that it had to be performed urgently.

4. We found there was no suitable opportunity to perform the surgery during the period from 21 March 2023 when Mrs D was discharged from hospital to 30 April 2023 when her haematoma had developed into and abscess and become infected, prompting her readmission to hospital. We found Mrs D was not well enough to undergo surgery following her readmission to hospital on 30 April 2023.

5. We found after diagnosing sepsis on 30 April 2023 the Trust failed to ensure appropriate antibiotic medication was provided to Mrs D. We have not identified any evidence so far to indicate this failure led to Mrs D’s death on 3 May 2023. However it is a significant failing and a missed opportunity to ensure her treatment was provided appropriately.

6. We will ask the Trust to act by providing an apology and an explanation of improvements.

38. We partly uphold Mrs A’s complaint. In considering our recommendations, we have referred to the NHS Complaint Standards. These standards state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

39. The NHS Complaint Standards also say that public organisations should seek continuous improvement and should use the lessons learnt from complaints to ensure that maladministration or poor service is not repeated.

Recommendation 1

40. We recommend that within one month of the date of our final report the Trust write to Mrs A to acknowledge and apologise for the impact the failings had.

Recommendation 2

41. We recommend that within three months of the date of our final report the Trust produce an action plan setting out the steps it will take (or the steps it has already taken) to reduce the risk of similar failings happening again in future. This action plan should be shared with us, Mrs A and the Care Quality Commission.