Management of weight loss
26. Ms S complains that over the course of eight months, Ms T continued to deteriorate and experienced significant weight loss, and this was not recognised or managed appropriately.
27. In response to the complaint, the Trust explained that Ms T had been reviewed by the dietitians throughout her admissions who had noted a steady weight loss through this period. She was noted to be 104kg on her first admission in March 2021, and 75.5kg during her last admission.
28. The Trust noted Ms T’s MUST score was calculated weekly, and she was prescribed supplements, snacks, and milky drinks between meals.
29. MUST is a tool designed to help identify adults who are underweight and at risk of malnutrition, as well as those who are obese. It is the first step in identifying patients who may be at nutritional risk and who may benefit from appropriate nutritional intervention (BAPEN).
30. The Trust said that although Ms T was not eating enough, she had declined nutritional supplements. The Trust says the ward team were monitoring her nutritional intake through food charts which showed a poor and variable intake. Overall, it considers the team took all appropriate steps to try and encourage a nutritious diet.
31. We will address each admission in turn and give a view on the nutritional management. Where there has been both nursing and dietetic involvement, we will address their input separately. We will refer to the following guidance:
32. NICE clinical guideline 32, which says:
• Screening for malnutrition should be carried out by healthcare professionals with appropriate skills and training (1.2.1).
• All hospital in-patients should be screened on admission and screening should be repeated weekly or when there is cause for clinical concern (for example, unintentional weight loss fragile skin and poor wound healing) (1.2.2).
• Nutrition support should be considered for people who have eaten little or nothing for more than 5 days and /or are likely to eat little or nothing for the next five days or longer (1.3.2).
• Care should provide food and fluid of adequate quantity and quality in an environment conducive to eating, and should provide appropriate support, for example, modified eating aids, for people who can potentially chew and swallow but are unable to feed themselves (1.1.2).
33. The CQC’s fundamental standards state that people should have care tailored to meet their needs, have enough food and drink to keep them in good health.
34. The NMC’s future nurse guidance says nurses must:
• 5 - Use evidence-based, best practice approaches for meeting needs for care and support with nutrition and hydration, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions • 5.1 - observe, assess, and optimise nutrition and hydration status and determine the need for intervention and support • 5.2 - use contemporary nutritional assessment tools • 5.3 - assist with feeding and drinking and use appropriate feeding and drinking aids • 5.4 - record fluid intake and output and identify, respond to, and manage dehydration or fluid retention • 5.5 - identify, respond to, and manage nausea and vomiting • 5.6 - insert, manage, and remove oral/nasal/gastric tubes • 5.7 - manage artificial nutrition and hydration using oral, enteral, and parenteral routes
35. The NMC’s Code says nurses must keep clear and accurate records (point 10) and must make a timely referral to another practitioner when any action, care, or treatment is required (point 13.2).
36. The BDA model and process for nutrition and dietetic practice, which sets out the expected content for a full dietetic assessment. This includes anthropometry (body measurements), biochemistry, clinical information, diet information, economic and social circumstances, treatment goals, interventions, and monitoring plans.
• 17 to 29 March 2021
37. We can see Ms T’s risk of malnutrition was assessed utilising MUST, and she was weighed on 18 and 27 March 2021. She had a low risk of malnutrition at these times and her weight remained stable at 104kg on 18 March and 102.7kg on 27 March. It is noted that she was consuming a normal diet and fluids. Our nursing adviser highlighted that the nursing assessment was inaccurate, as Ms T had dentures (upper set) which were not recorded at the time.
38. It is documented that Ms T was eating and drinking ‘good amounts’ on one occasion during this admission; however, we cannot see reference to eating and drinking on a daily basis. It was deemed that nutritional care plan not needed.
39. Overall, we understand during this admission Ms T had a low risk of malnutrition, and her weight remained stable. Her assessment did not prompt the need for a nutritional care plan. We consider Ms T’s nutritional needs were met in line with the NICE, CQC, and NMC guidance outlined above. For this reason, we consider there was no service failure relating to nutritional management for this admission.
• 31 March to 15 April 2021
40. The records show Ms T’s risk of malnutrition was assessed utilising MUST on 1 and 9 April. Her risk of malnutrition was low and there was minimal weight loss during this admission when compared to her usual weight of 104kg. She weighed 102kg on 1 April and 100.8kg on 9 April.
41. It is documented that Ms S Preistley was consuming a normal diet and fluids. The tissue viability nurses (TVN) requested a dietitian referral on 1 April 2021, however, there is no evidence that she was referred to the dietitian as requested by TVN. The rationale for referral was not stated, however it is presumed that it was to aid wound healing.
42. Overall, Ms T’s risk of malnutrition was low during this admission, and therefore did not prompt the need for a nutritional care plan.
43. However, we consider the record keeping regarding food intake is poor. There is very little reference to eating and drinking within the records. Additionally, Ms T was not referred to the dietitians, as requested by the TVN. We consider this is a service failure, as it is not in line with the NMC and NICE guidance we have quoted above.
44. We will address the impact of this later in our report.
• 24 July to 17 September 2021
Nursing
45. Within the records, the admission document states a nutritional assessment had not been completed and a nutritional care plan had not been put into place. Ms T’s risk of malnutrition was assessed utilising MUST on 25 July, but this assessment was incomplete as she was not weighed. This meant the assessment was not useful in calculating her risk of malnutrition.
46. This was repeated on 31 July 2021. Ms T weighed 93.5kg, which was a 10% weight loss from her usual of 104kg. It was repeated on 7 August 2021, and Ms T weighed 82.2kg, this was a 20% weight loss from her usual weight.
47. Our nursing adviser highlighted that Ms T was assessed as at medium risk of malnutrition on 31 July, which is incorrect because her 10% weight loss alone would score two and high risk (BAPEN). Ms T was then correctly scored as high risk on 7 and 14 August.
48. The MUST was repeated on 20 August 2021. We can see that Ms T’s height had been recorded incorrectly as 1.26m (having previously being recorded as 1.5m throughout her admissions), and her usual weight had been incorrectly recorded as 81kg (which should have been 104kg).
49. Ms T had lost further weight by this point, weighing 79.5kg. We have identified that Ms T’s MUST was incorrectly calculated again on 27 August, 8 September, and 16 September, as the incorrect height and incorrect weight had been recorded. This gave an alarming outcome of no weight loss, especially when considering Ms T had lost over 20kg.
50. On 31 July, a nutritional needs care plan was documented as being commenced. However, it is blank and therefore of no use. The nursing evaluations contain some references to Ms T eating, but they are not consistent and therefore do not give us a full picture.
51. Food charts were in place between 1 August and 6 August, but show a fluctuating nutritional intake, and the charts are poorly completed. We understand they should have been in place throughout the whole admission.
52. On 6 August, it is noted Ms T was not eating much and that she was encouraged to eat. Ms T advised the nursing staff she could not, but the reason for this was not explored any further. On the following day, Ms T was documented as “just drinking milk”. The nursing evaluations from this point onward describe a very poor intake.
53. On 13 August and 19 August, the TVN requested the nursing team made a referral to the dietitian. Ms T was referred to the dietitian for the first time on 20 August.
54. On 23 August, Ms T was seen by the renal team who documented she had experience significant weight loss. Her weight is documented as 79.5kg. Ms T was asked, for the first time, why she thought she may have lost weight. She reported having no appetite, severe indigestion, and said some food was getting stuck when she swallowed. Ms T was seen by the dietitian on the same day, and nutritional supplements were prescribed and administered from 25 August.
55. Overall, we consider there are service failures in the care provided during this admission. Ms T’s nutrition was not managed in line with the NICE, NMC, and CQC guidance we have quoted earlier in the report. The nursing team did not make any attempts to understand why Ms T could not eat, and significant weight loss was not identified until 23 August. There are inconsistent and incomplete nutrition charts, meaning her intake was not monitored throughout the admission. In addition to this, the MUST assessment was delayed, and was calculated incorrectly on several occasions, as detailed above.
56. We will address the impact of this later in our report.
Dietitian
57. Ms T was first seen by the dietetic team on 23 August. We can see from the records the initial review considered some of the relevant information as outlined in the BDA guidance. However, the review did not seem to note Ms T’s learning disability, and this would be expected to be taken into consideration as this could affect her food choices and dietary habits.
58. We understand that the BDA provides guidance on how to best support those with learning disabilities with nutrition within a care setting. This guidance highlights that this population has an increased risk of premature death, obesity, infections, poor swallow, and poor nutritional status. They have greater needs than the general population. Despite this, whilst in hospital, we cannot see there was any consideration given to Ms T’s additional needs, such as easy read information.
59. We also consider the dietitians could have undertaken a more thorough review of Ms T’s current oral intake through a diet history. We recognise that whilst a food chart review would have been helpful, the poor record keeping on the ward would have complicated this. The dietitians could also could have calculated her daily calories and protein intake.
60. We can see the monitoring plan put into place simply states “will review”, and our dietitian adviser explained it would be best practice to include a more detailed review plan, including advice on when to seek advice from the team sooner, (e.g., if Ms T was not accepting any food supplements).
61. Despite this, we understand that the advice given at the end of the assessment was in line with guidance from NICECG32 and was both appropriate and evidence based.
62. Ms T had follow-up appointments with the dietitians on 26 August, 3 September, and 10 September. Unfortunately, these assessments also lacked any detailed record of her current oral intake. On 10 September, the dietitian has noted Ms T was for no further input, but there is no justification or explanation for this. This should have been noted.
63. Overall, we consider the assessment was not in line with the BDA guidance as dietitians did not consider all the relevant information required to ensure a holistic view was reached, and to ensure the most appropriate support was in place for Ms T with regards to her additional needs. We consider this was a service failure.
64. We will address the impact of this later in our report.
• 21 September to 8 October 2021
Nursing
65. Ms T was very unwell on admission and was documented as vomiting and unable to keep anything down. On 23 September it is documented that her appetite was poor and that she had lost five stone over six months. Despite this, her MUST calculation incorrectly concluded low risk due to “no unplanned weight loss in the last three to six months”.
66. A nutritional care plan was partially completed on 23 September, but it did not include details of Ms T’s likes and dislikes, her usual appetite and pace of eating. Intake was poorly documented on this date, and it is not clear how much food Ms T ate and the intake chart on 24 and 25 September are blank. Intake from 1 to 8 October was very poor, and there is no evidence of requesting further dietitian input despite deterioration.
67. Overall, we consider there has been a service failure, as the management of Ms T’s nutrition and weight loss was not in line with the national guidance quoted earlier in our report. There are clear indications of service failure relating to this part of the complaint.
Dietitian
68. Ms T had a follow up assessment with the dietetic team on 28 September, following reports of further weight loss. We can see this was not as detailed or comprehensive as the first assessment undertaken on 23 August. The assessment has not included updated information such as weight change calculations, biochemistry, or oral intake. Furthermore, the dietitian did not communicate with Ms T, and it is noted that there was no plan to see her face to face unless anything changed.
69. The BDA guidance explains that new nutritional issues or a lack of progress should lead to a reassessment and may lead to a change in the nutrition and dietetic diagnosis, strategy, and/or implementation (Step 5).
70. In line with this, we consider a full review should have been done, and our dietitian adviser explained that best practice would have been to provide a new assessment to see if Ms T’s situation had changed since the previous dietetic input in the previous admission. Additionally, as there were reports of poor oral intake and ongoing weight loss, a refeeding assessment should have been completed, in line with NICECG32. We cannot see this was done.
71. We consider this was a service failure, as it was a missed opportunity to engage with Ms T, especially as there was a significant degree of ongoing weight loss, a poor clinical picture, and ongoing poor oral diet. We address the impact of this in the next section of our report.
Impact
72. We will now consider the impact of the failings we have identified in the nursing and dietetic care provided to Ms T over the course of her admissions.
73. We note that Ms T had a body mass index (BMI) of 45.8 on initial admission. BMI is an index of weight-for-height commonly used to classify overweight and obesity. In adults, overweight is defined as a BMI of 25 or more, whereas obesity is a BMI of 30 or more (WHO).
74. The WHO outlines that obesity has many negative impacts on health including cardiovascular disease, diabetes, and some cancers. For this reason, we understand a steady controlled weight loss through a balanced nutritious diet, guided by the dietitian, would therefore have benefitted Ms T. However, this is not what happened during these admissions.
75. The poor record keeping in relation to food and fluid intake means that it was difficult to see a full picture of Ms T’s intake during her admissions. We consider this likely impacted on the nurse’s ability to recognise the need for intervention and support, which ultimately delayed the dietetic input in this case.
76. The inaccurate completion and miscalculation of the MUST assessments has contributed to this, as it resulted in inaccurate risk scores, which contributed to the delays in recognising and acting upon Ms T’s level of risk, and her significant weight loss.
77. These failings meant there were several missed opportunities for dietitian involvement in Ms T’s care. We also consider the poor record keeping would have also impacted upon the dietetic assessments, as crucial information was missing which would have informed the background of their reviews.
78. The failure to refer Ms T to the dietitians on 1 April represents the first missed opportunity for earlier dietetic intervention in her care. We consider this would have allowed for earlier recognition of any nutritional issues, and for interventions to be put into place to optimise her nutritional status. Our dietitian adviser explained that if the MUST screening tools had been completed correctly, a referral should have been sent by 31 July 2021, at the very latest.
79. Further to this, we consider the impact of not taking Ms T’s learning difficulties into consideration, not having an effective monitoring plan, and not re-assessing Ms T on 28 September was that the dietetic team failed to provide adequate care and missed opportunities to attempt to engage Ms T, who by this point, was a nutritionally highly vulnerable patient.
80. In our view, the failures in identifying Ms T’s nutritional risk combined with the delay in providing nutritional care and support had a detrimental impact on her recovery throughout her admissions.
81. During these admissions, Ms T did not eat or ate very little, she lost a significant amount of weight in a short time. It is important to note that even though she remained obese with a BMI of 37.9 when she weighed 79.5kg on 20 August 2021, both our nursing adviser and our dietitian adviser explained that she was most likely becoming malnourished, and at risk of both macro and micronutrient deficiencies.
82. NHSE says common signs of malnutrition includes unintentional weight loss. Losing 5% to 10% or more of weight over 3 to 6 months is one of the main signs of malnutrition.
83. Most people who are malnourished will lose weight, but it is possible to be a healthy weight or even overweight and still be malnourished. For example, this can happen if someone is not getting enough nutrients, such as some types of vitamins and minerals through their diet.
84. Other symptoms of malnutrition include:
• reduced appetite • lack of interest in food and drink • feeling tired all the time • feeling weaker • getting ill often and taking a long time to recover • wounds taking a long time to heal • poor concentration • feeling cold most of the time • low mood, sadness, and depression
85. Our dietitian adviser has explained that due to Ms T’s infection and skin integrity, it is highly likely she would have had increased nutritional needs. Her rapid and ongoing weight loss demonstrated that she was not able to meet her nutritional requirements alone, and we understand this is highly likely to have had a significant detrimental impact on her ability to fight infection and wound healing.
86. We consider that earlier intervention from the dietetic team may have resulted in a slowing, or even halting, of Ms T’s weight loss. We can see from the records there were ongoing concerns with infections, pain, wound healing, vomiting and poor appetite.
87. We consider earlier intervention may have allowed for improved wound healing and less infection. We recognise this would have also resulted in significantly less distress for the family, and for Ms T who was most likely in ongoing pain and was unable to eat.
88. Whilst we cannot say this caused Ms T’s death, as she very sadly died from cancer of an unknown origin, the clinical advice we have received supports the view that these failings meant Ms T was not given the best chance of surviving for longer, because she had a reduced tolerance to fighting infection and illness.
89. We recognise these findings are particularly serious, and we acknowledge this is likely to add to the family’s bereavement and cause them frustration and distress. The emotional impact of this should not be underestimated. We also recognise this is likely to be exacerbated by our report, and we are sincerely sorry for any additional distress our report causes.
90. We consider this is likely to have a lasting impact on the family, as they come to terms with the care Ms T received, and the missed opportunities we have identified in this report.
91. We cannot see that this has been addressed by the Trust in its complaint responses, and so we will make a recommendation for the Trust put things right.
Investigations for cancer
92. Ms S complains that the Trust missed an underlying diagnosis of cancer throughout Ms T’s presentations between March and November 2021.
93. In response to the complaint the Trust says the correct management was followed throughout Ms T’s admission and attendance at the hospital, and relevant investigations were completed. It explained that Ms T underwent detailed investigations prior to her diagnosis, in the form of gastroscopy and CT imaging, which confirmed there were no cancerous tumours, and showed a hiatus hernia and inflammation only. The Trust added that the small lung nodule was felt to be a small cystic like lesion, and following review was required to be monitored on an annual basis, in line with the national guidelines.
94. In this section of our report, we will refer to the GMC’s Good Medical Practice guidance, which says:
“15 - You must provide a good standard of practice and 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 services the patient’s needs.”
95. We can see from the records that Ms T had multiple presentations to the Trust over this period, as well as a couple of presentations in early 2021. Ms T underwent a colonoscopy in February 2021, which was reported to be normal. The records also detail Ms T had an ovarian cyst which was followed up with the gynaecology team in 2019.
96. Initially, between March and July the presenting issues were leg ulcers and infection. She then presented with some generalised weakness and renal impairment in August.
97. We can see that in August 2021, Ms T underwent a pelvic ultrasound and an abdominal ultrasound. There were no major findings in these investigations. The ultrasound on 3 August reported thickening in the endometrial lining and a large ovarian cyst on the left side. An ovarian cyst is a fluid-filled sac, most are usually harmless.
98. The results of the ultrasound of 3 August were discussed at the gynaecology multi-disciplinary team (MDT) meeting, and it was decided that as there had not been much change compared to the findings in 2019, no further action was required with regards to the cyst. With regards to the thickening of the lining of the womb, a referral was made for a hysteroscopic diagnostic procedure to be arranged. We consider these actions were in line with the GMC’s Good Medical Practice guidance, as outlined above.
99. The ultrasound on 13 August found a small hepatic cyst in the liver. A hepatic cyst is a fluid-filled sac, most are benign and do not cause symptoms. Our physician adviser confirmed that the results of this scan did not demonstrate any worrying features which would require further investigation, nor raise the suspicion of an underlying cancer.
100. Later in September, Ms T was admitted due to nausea and vomiting. She underwent a gastroscopy on 1 October, and the findings showed severe inflammation and ulceration. There was suspicion of a tumour in the oesophagus, but a biopsy confirmed no cancer was present at the time.
101. A CT scan of the chest, abdomen, and pelvis was undertaken on 5 October. This confirmed there was no obvious tumour or mass. However, this did show a small right lower lung nodule, which was noted to have grown from 3mm to 5mm. Our physician adviser explained that there are no other worrying features which would suggest the presence of metastatic lung cancer, and 12-month surveillance, as indicated in the Trust’s response, is in line with the BTS guidelines.
102. On 14 October, Ms T was referred for a repeat gastroscopy to ensure healing and exclude any underlying malignancy. This took place on 14 November. The notes indicate that the clinician encountered a stricture (narrowing of the throat), and the procedure had to be abandoned due to Ms T’s heart rate becoming abnormally fast. The clinician stated cancer was not excluded and they had arranged further investigations, and the referring consultant was to be made aware. Based on the information we have seen we consider these actions were in line with the GMC’s Good Medical Practice guidance.
103. We must acknowledge that Ms T had a significant weight loss over the course of her admissions. Our physician adviser has explained that weight loss is a very non-specific symptom which can relate to many medical and psychological conditions. We have explored the possible causes of this earlier in our report. As Ms T did not appear to have any significant red flags for cancer until the findings of the gastroscopy on 14 November, the weight loss would not necessarily have triggered further investigations.
104. We understand Ms T rapidly deteriorated and was admitted to a hospital, which is part of a different NHS Trust, on 22 November 2021. We have been unable to source the medical records for this admission, but we understand during this admission Ms T was diagnosed with cancer.
105. The primary site of the cancer could not be identified because Ms T was too unwell for further investigations. As we do not have the records from this admission, and because we do not know the primary site of the cancer, we cannot know how or when the cancer developed. We recognise this uncertainty must be distressing for the family.
106. What we can see from the records that Ms T underwent several examinations during her presentations to hospital, which were ordered based upon her symptoms at those times. We can also see she was referred to the appropriate clinical teams, for ongoing monitoring and surveillance, and further investigations where needed. We consider this was in line with the GMC’s Good Medical Practice guidance.
107. For this reason, we do not uphold this aspect of the complaint.
Management of biopsy
108. Ms S complains that Ms T required a biopsy on her leg whilst an inpatient on the short stay unit, but this was not performed due to two clinical specialities being reluctant to take responsibility for her care. She complains that the biopsy was cancelled and rescheduled and was never carried out.
109. In response to the complaint the Trust has explained that there was no reluctance to take responsibility for Ms T’s care, and she was reviewed by several teams during her admissions.
110. The Trust explained that the biopsy could not be completed until there were initial signs that Ms T was responding well to antibiotic treatment. It says this took longer than expected during the admission, as the improvement was gradual. At the time of discharge on 17 September, and after discussion with the microbiologist, Ms T’s antibiotics were changed from intravenous (IV) to oral, enabling her to continue with these at home for the next 10 days.
111. The Trust says the vascular surgery team assessed Ms T during her admission and planned to meet her as an outpatient to discuss the biopsy. This was scheduled to take place on 19 September 2021. No further information about the biopsy has been provided by the Trust in its responses.
112. The records show us that during this admission, there were ongoing discussions regarding the plan of management of Ms T’s leg ulcers.
113. Ms T had an MRI scan of the right leg on 26 August 2021. The notes say there was evidence of extensive tissue oedema (a build-up of fluid which leads to swelling) in the leg with skin thickening which reflected cellulitis (a skin infection) and superficial fasciitis (meaning the infection was under the skin). It was highlighted that there was a fluid collection in a deeper layer of skin which raised a concern for necrotising fasciitis (a serious bacterial infection which results in the death of soft tissue). The radiologist recommended urgent review by the appropriate team.
114. Ms T was discussed with the trauma and orthopaedics team on 27 August who advised it was unlikely to be necrotising fasciitis and advised for the TVN team to continue with the management of the wounds, as well as antibiotic treatment. There was a further discussion on 31 August 2021 with the microbiology team who advised orthopaedics should be contacted for their opinion and to continue with current antibiotic treatment.
115. On 2 September, the microbiology team suggested draining the fluid collection and sending a sample to them for further investigations. This was discussed with the orthopaedics team who advised that there were no clinical indications of necrotising fasciitis. It was felt that the collection found in the MRI was subcutaneous oedema (swelling in a deep layer of the skin), and therefore gave the view that there was no indication for drainage or surgical intervention. The orthopaedics team suggested discussion with the TVN team for a deep tissue sample.
116. On 6 September, the TVN team advised they do not carry out deep tissue samples. The microbiology team advised Ms T was already on the optimum antibiotic treatment, and any further changes would need samples of the fluid to be obtained first. A plan was made to re-refer Ms T to the trauma and orthopaedics team for further input.
117. Ms T was discussed with the trauma and orthopaedics team again on 7 September. They advised that to take a sample and drain from the deep tissue they would need to contact the plastic surgery team who were not based locally. It was recommended Ms T required a vascular review as it may be vascular insufficiency that was causing the poor healing of the ulcers.
118. Ms T was reviewed by the vascular team on 9 September who recommended a referral for a duplex scan, an ankle-brachial pressure index (ABPI), and for Ms T to be seen in the vascular clinic as a follow up.
119. On 13 September, the microbiology consultant advised that the deep collection needed draining and without this being done it was unlikely the infection would resolve. The notes suggest a referral to the surgical team to progress this request. On 14 September, the surgical team recommended a referral to trauma and orthopaedics for the deep tissue sample and the request for a sample was escalated to the nurse in charge.
120. Notes from 16 September detail that there had been discussion with the trauma and orthopaedics team, the TVN team, and surgical team, but all had said it was not under their speciality to carry out the deep tissue biopsy. Further discussion with the trauma and orthopaedics team suggested that the infection was on a background of possible vascular insufficiency, and so vascular input was required.
121. The notes from 17 September state Ms T was awaiting transfer to a different hospital within the Trust for a biopsy to be undertaken by the vascular surgeons. A later entry states Ms T was to be discharged with a follow up appointment in place for review by the vascular team on 19 September 2021. We cannot see this appointment took place.
122. There is a referral to the vascular team for a deep tissue biopsy within the records dated 21 September 2021, and on this referral, it is noted that a clinic appointment was made for 20 October 2021.
123. The clinic letter from the appointment on 20 October 2021 indicates that Ms T was reviewed in the vascular clinic. The letter indicates Ms T was examined physically with the use of a doppler scan (a type of ultrasound) which is less invasive than a biopsy. A plan was made for further venous and arterial duplex scans to ensure there was nothing further they could do to treat or improve to allow the ulcers to heal. There is no mention of the biopsy in this clinic letter.
124. It is evident from the records that Ms T’s care was discussed with the vascular surgery team, trauma, and orthopaedics team, the TVN team, and the microbiology team. During this time, she was being treated with antibiotics, and the wounds were being managed by the TVN’s. We consider this was in line with the GMC’s Good Medical Practice guidance, as care was provided, advice was sought, and Ms T was referred to the relevant teams for further consideration.
125. However, the GMC’s guidance also says doctors must communicate effectively and give patients and those close to them the information they want or need to know in a way they can understand (point 32 and 33). There appears to have been miscommunication amongst the teams about which team was responsible for conducting the biopsy which had been recommended. We cannot see this was explained to Ms T or her family.
126. We understand Ms T was not sent for a biopsy on 17 September as planned because the team was waiting for initial signs she was responding well to antibiotic treatment. We cannot see any explanation in the records or within the Trust’s complaint responses why Ms T’s outpatient appointment on 19 September did not go ahead, but we acknowledge this was likely because they were waiting for the antibiotic treatment to take effect.
127. We acknowledge that Ms T was assessed by the vascular team on 20 October 2021, which was part of the treatment plan. The clinic letter says that other, less invasive, options were being explored. We consider this evidences that alternative investigations were arranged, in line with the GMC’s Good Medical Practice guidance.
128. However, there is no explanation within the clinic letter which addresses why the biopsy had not been carried out. For this reason, we consider there has been a service failure in the communication with Ms T and her family.
129. We understand how the miscommunication amongst the teams, and lack of explanation given to the family, led to Ms S’s concern that no one was taking responsibility for Ms T’s care, and that no action was being taken in relation to Ms T’s leg ulcers. We cannot see that this has been addressed by the Trust in its complaint responses, and we will make a recommendation for the Trust put things right.