Locala
20. Mrs M complains community nurses did not act when fluid was leaking from Mr M’s drain wound site excessively. She says they did not swab the wound or contact the hospital for advice. Mrs M says although they took Mr M’s temperature on the initial visit, the nurses never did this again. She says they changed the dressing and provided large pads to put over the dressing if it got wet again. Mrs M feels this was a breeding ground for bacteria.
21. We have obtained Mr M’s medical records from these visits and sought clinical advice from our nurse adviser. The records show that the nurses were going to visit Mr M twice weekly on a Monday and Thursday to drain the fluid from the pleural space, clean the skin around the site, and change the dressing. Draining was to commence on 23 December.
22. Our nurse adviser said nurses should follow the NMC standards when delivering patient care. This guidance says nurses should:
• respect the skills, expertise, and contributions of your colleagues, referring matters to them when appropriate • work with colleagues to preserve the safety of those receiving care • share information to identify and reduce risk • accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care • demonstrate the ability to accurately process all information gathered during the assessment process to identify needs for individualised nursing care and develop person-centred evidence-based plans for nursing interventions with agreed goals • share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand.
23. The nurses first visited Mr M on 23 December. The documentation from this date does not refer to any concerns with fluid output, the drain site, or the patient’s condition. The nurses documented that Mr M was feeling well and that there were no signs of infection. Our nurse adviser said there is no indication from this visit that nurses needed to do anything other than follow the chest drain management plan.
24. On observation Mr M showed no signs of worsening physical health. Our nurse adviser said the care provided by the nurses on 23 December was in line with the NMC standards which says to accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care. Taking this advice into account, we can see no indications of failings in the care provided at this appointment.
25. On 25 December, the nurses documented Mr M requested an unscheduled visit because the drain site was leaking, and the dressing was wet. The documentation from this visit confirms that the drain was leaking around the insertion site. In addition to the insertion site leaking, the nurses documented the surrounding skin as being ‘red’.
26. Our nurse adviser said at this point, due to the leaking of the drain and the redness of the surrounding skin, the nurse should have asked Mr M if he could have displaced the drain, how he was feeling, or if there was any pain from the site. Our nurse adviser said the nurse should have taken physiological observations to ensure Mr M’s clinical condition was stable. This would have been in line with the NMC standards. This did not happen which is an indication of a failing.
27. The nurses visited Mr M again on 27 December. At this visit, the nurse documented Mr M ‘feels well’. They documented the drain insertion site was itchy with some patchy redness. Mr M also reported ‘intermittent pain’. It appears the nurse associated this with the leaking rather than an infection.
28. Due to the continued leaking of the drain, the redness and itching of the surrounding skin and the pain our nurse adviser said the nurse should have sought further advice from the ward. They also said the nurse should have taken physiological observations to ensure Mr M’s clinical condition was stable. This would have been in line with the NMC standards. This did not happen which is again an indication of a failing in this aspect of care.
29. Mrs M says this failure to act on the infection by the nurses led to her husband requiring an admission to hospital with sepsis. She says her husband recovered from sepsis but contracted COVID-19 two weeks later in hospital and died. She questions if her husband’s death was avoidable. She says this has caused her considerable grief and has changed her life. We were sorry to hear of how distressing this has been for Mrs M.
30. Our nurse adviser said redness and itching around the drain site can indicate several concerns, one of which is infection. She said it is now not possible to rule infection out on 25 and 27 December as nurses did not assess Mr M for signs of worsening physical health.
31. Our nurse adviser said the wound may have been infected at the time of the appointments or, or it may have become contaminated by Mr M itching the area. She also explained wound leaking also increases the risk of infection. Our nurse adviser said by not investigating further and seeking advice, the nurses increased the likelihood of Mr M requiring a hospital admission.
32. However, she also explained there is a risk of infection with any drain, and this risk increases the longer the drain is in place. As such, it is possible that Mr M may have required an admission to hospital regardless of if the nurses had taken earlier action. It is also possible the nurses may have found the wound was not infected on either 25 or 27 December even if they had assessed for this.
33. We cannot attribute Mr M catching COVID-19 in hospital or his death from this to the actions of the nurses on 25 or 27 December. This is because there are too many possibilities of what may have happened between the nurses visiting him up to him contracting COVID-19. We therefore do not feel we can link these failings to this.
34. Having said that, the indicated failings increased the likelihood of Mr M requiring a hospital admission. We therefore think there is an indication of injustice here as this leaves Mrs M with some uncertainty.
35. We also note there was a three-and-a-half-month delay in Locala responding to Mrs M’s complaint beyond the target date it initially advised her. Mrs M also felt that the response was inadequate.
36. Locala have agreed to undertake some further work on Mrs M’s complaint to address the indicated failings in care and complaint handling and the impact they had. It has agreed to acknowledge the indicated failings, apologise, and explain what it will do differently in future. We consider this provides a resolution to this part of Mrs M’s complaint.
LTHT
37. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right. Having done so we have not found any indication the issues raised about LTHT had a negative impact on Mr M.
38. Mrs M complains about the advice ward J84 gave her husband when he contacted it on 28 December 2021 regarding his pleurx drain. Mrs M says a sister on the ward advised Mr M his symptoms were not related to his operation but could be COVID-19, advising him to call 111. Mrs M says the nurse did not ask more questions or ask Mr M to take a COVID-19 test and ring back. She says she could have asked Mr M to come into the nurse led clinic for review.
39. Mrs M says her husband did not have COVID-19 (a test later that day was negative) and his wound was infected and so her husband should have been admitted to ward J84. Mr M was instead admitted to a hospital under CHNFT just after midday and treated for sepsis. In the complaint response from LTHT it acknowledged it could have invited Mr M into the nurse led clinic the following day.
40. There are no documented medical records from this discussion and so we only have Mrs M’s account of what occurred. We have no reason to dispute this account. However, it is now difficult to say what the nurse taking the call should have done at this point. It is possible they should have invited Mr M into the nurse led clinic the following day.
41. However, we cannot see there is an indication of an impact on Mr M because of this. This is because at the time of these events, the nurse led clinic would usually not occur until the following day (a Wednesday). Our physician adviser confirmed that Mr M was too unwell to wait until the next day for assessment. Mr M attended A&E shortly after making the phone call which was the correct place for his sepsis to be treated.
42. We were truly saddened to hear that Mr M caught COVID-19 and died during this admission and for the devastating impact this had on Mrs M. We hope this provides her with some reassurance there is no indication LTHT’s actions contributed to this.
CHNFT: admission to four bed ward
43. Mrs M complains CHNFT admitted her husband (who had a compromised immune system and sepsis) to a four-bed ward. She feels it should have placed him in a side room to minimise the risk of him catching COVID-19. We understand why this caused Mrs M concern.
44. The infection prevention and control guidance provided advice at the time of these events around patient placements in the hospital setting.
45. This outlined that in the hospital setting, staff should place patients with respiratory symptoms in a single room, ideally with en-suite facilities. It states that those with underlying conditions who are at higher risk of severe outcomes should be prioritised for placement in single rooms whilst awaiting testing. There was nothing specific in this guidance at the time around placing immunocompromised patients into side rooms if they had tested negative.
46. Taking the above into account, we can see no indication of failings here. This is because the guidance at the time did not require Mr M to be placed in a single room.
CHNFT: COVID-19 medication
47. Mrs M complains her husband was not started on medication for COVID-19 until a week after testing positive.
48. We can see from the medical records that the treating team prescribed Mr M dexamethasone (a steroid) on 23 January. This was a week after he tested positive. The COVID-19 rapid guideline recommends doctor should start patients on dexamethasone when they need oxygen supplementation to maintain their oxygen levels within normal limit. We can see the doctors started Mr M on dexamethasone at the point he began to require oxygen supplementation.
49. The treating team also prescribed Mr M tocilizumab on the 31 January. The COVID-19 rapid guideline recommends tocilizumab for patients who are on dexamethasone, are continuing to require supplemental oxygen, and their C-reactive protein (CRP) is greater than 75. Our physician adviser explained this is due to the efficacy of this drug not being proven in COVID-19 infection if the patients CRP level is not elevated.
50. We can see that at the time doctors prescribed this medication, Mr M’s CRP was less than 75 which was outside the criteria for this medication to be started. However, we note doctors discussed this at the time and given Mr M’s deterioration, they agreed to commence it. Our physician adviser had no concerns about this.
51. The COVID-19 rapid guideline required the treating team to prescribe either of these drugs to Mr M any sooner. We have therefore seen no indication of failings in this part of the complaint. We hope this provides some reassurance to Mrs M.
CHNFT: Low risk ward following contracting COVID-19
52. Mrs M complains CHNFT put Mr M on a low risk COVID-19 ward after he contracted COVID-19. The infection prevention and control guidance in place at the time said that if a single room is not available then to ‘cohort patients with confirmed respiratory infection with other patients confirmed to have the same infectious agent’.
53. In line with this, we would expect any patients to be either placed in a single room if available or on a ward with other patients who are COVID-19 positive. Mr M was placed on a ward with other COVID-19 patients and so CHNFT’s practice was in keeping with this guidance. As such, we have seen no indications of failings in this area of the complaint.
CHNFT: catheter
54. Mrs M complains staff did not remove Mr M’s catheter despite them telling him on two occasions they would do. She is concerned this delayed his discharge.
55. The records show Mr M had a catheter inserted on 28 December. The catheter care guidance outlines the clinical indications for catheterisation, one of which is monitoring renal function hourly during a critical illness. Mr M was admitted with sepsis and would fall under this criteria for monitoring of urine output.
56. We can see there was a review of Mr M’s catheter on the 29 December in the medical notes and doctors planned to remove the catheter if his renal functions improved. Mr M had an ongoing acute kidney injury and sepsis for which he needed an ongoing catheter.
57. Our physician adviser said from the clinical records a catheter was indicated and any delay in removing the catheter did not have any impact on Mr M’s discharge. This was because the treating team planned to move him to a thoracic centre for management of his chest drain. Sadly, he contracted COVID-19 before this occurred.
58. Taking the above information into account, we can see no indications of failings or an impact on Mr M.
59. We thank Mrs M for bringing her complaint to us. We hope we have been able to fully explain the reasons for our decision.