Delay in identifying infection in the heel in April 2022 17. Mrs Y says the Trust failed to identify the infection in her husband’s heel early enough despite her telling them that his heel was the cause of his infection. She says if the Trust had identified the infection in his heel sooner it may have been able to provide treatment sooner and he may not have needed to have his foot amputated.
18. The NICE diabetic foot guidance says clinicians should assess patients as high risk when they have a history of previous amputation and/or a current diabetic foot problem, such as ulceration or infection. The NICE diabetic foot guidance says if a diabetic foot infection is suspected and a wound is present, clinicians should send a soft tissue or bone sample from the base of the debrided (where damaged tissue has been removed) wound or, if not possible, consider a deep swab. They should also consider an X-ray of the foot to determine the extent of the problem.
19. The NICE diabetic foot guidance advises clinicians to consider osteomyelitis (infection of the bone) if a person with diabetes has an infection, a deep foot wound, or a chronic wound. If osteomyelitis is suspected but not confirmed by an initial X-ray, clinicians should consider an MRI to confirm the diagnosis.
20. Mr Y had an existing diabetic foot ulcer which the district nurses believed may be infected and for which he was taking antibiotics. When he attended the ED on 28 March 2022 the records indicate the doctor queried whether he may have osteomyelitis in his foot and removed the bandage to assess his foot ulcer. The record of this assessment indicates the doctor found no evidence of infection.
21. After he was admitted to the ward for treatment of his pleural effusion the Trust continued to monitor and assess his foot. The Trust performed an X-ray of his foot which did not identify any bone abnormalities and referred him to its podiatry service for management of this ulcer.
22. The doctor examined his foot on 2 April 2022 and noted the ulcer ‘looked superficial’ and showed no signs of pus (a thick fluid containing dead tissue cells and bacteria often produced by the body when it is fighting infection) or cellulitis (bacterial infection of the skin). The Trust did not consider his foot to be the source of infection at that time and the Trust’s podiatry team provided treatment to wash out and remove damaged and infected tissue from the ulcer on 8 April 2022.
23. The records indicate there was a change in the ulcer on 12 April 2022 when the clinicians noted an unpleasant smell. The clinicians noted the ulcer still appeared relatively dry with no obvious signs of infection at this time and took no further action. The records indicate the Trust discharged Mr Y home on 14 April 2022 with a referral to the district nurses for wound care on his foot.
24. In line with the NICE diabetic foot guidance Mr Y was a high risk patient due to his previous amputation and current diabetic foot ulcer. Our podiatrist adviser said in light of the development of an unpleasant odour from the ulcer it would have been in line with the NICE diabetic foot guidance to consider a further X-ray prior to discharging Mr Y.
25. It is not possible to say, even on balance of probabilities whether an X-ray would have identified infection or osteomyelitis in Mr Y’s heel at this time. This is because we can see that when initial investigations were carried out when he returned to hospital a few days later, it wasn’t clear even at that later stage whether there was infection or osteomyelitis in his heel. However we think the decision to discharge him on 14 April 2022 without carrying out a further X-ray was a missed opportunity to consider tests that may have better informed the Trust of Mr Y’s condition.
26. Mr Y returned to the ED on 19 April 2022 suffering with fever, uncontrolled blood sugar and urinary retention. The records indicate the Trust suspected his symptoms were due to sepsis (a serious condition that occurs when the body has an extreme reaction to an infection) and commenced treatment with broad spectrum antibiotics (antibiotics used to treat a variety of bacterial infections). The records indicate Mrs Y told the Trust she believed her husband’s foot was the source of infection, however the Trust believed the source was a urinary tract infection or resulting from problems with his liver.
27. The Trust performed blood tests and took a swab of the ulcer 20 April 2022 which identified bacterial infection. The Trust sought advice from its microbiology team who recommended they continue the antibiotic treatment for a further 7-14 days.
28. The Trust’s diabetic foot clinic reviewed Mr Y’s foot on 21 April 2022 and noted the ulcer had increased in size. The clinicians noted softness in the centre of the ulcer but it was relatively dry with no obvious signs of a collection of pus.
29. Both our physician and podiatrist advisers said it is at this point that there were signs of a deterioration in the ulcer. The Trust podiatrist noted it had increased in size, looked ‘boggy’ (soft with dead tissue that is dark in colour), and they suspected ‘deep necrosis’ (death of cells and tissue underneath the wound).
30. The Trust performed an X-ray of Mr Y’s foot on 22 April 2022. The records indicate the clinicians suspected Mr Y may have an infection in the bone of his heel and considered whether an MRI scan should be performed to confirm this. However no MRI was carried out.
31. The records indicate the Trust clinicians still felt it was possible his infection was due to his liver and performed an abdominal CT scan on 23 April 2022 which identified a possible collection of fluid around Mr Y’s liver. The Trust performed an ultrasound scan of his liver on 24 April 2022 which identified possible mild venous congestion (increased pressure in the veins that obstructs the drainage of blood from the organs).
32. The doctor and podiatrist examined Mr Y’s foot on 25 April 2022 and whilst removing the damaged tissue from the ulcer a large collection of pus drained from the area. At this point the clinicians identified Mr Y’s foot was deeply infected and the records indicate the clinicians believed it was likely the infection had reached the bone.
33. The Trust performed another foot X-ray on 26 April 2022. The report of the X-ray states ‘no periosteal reaction (formation of new bone in response to abnormal stimuli) or destructive bony change to suggest osteomyelitis’. The records indicate the clinicians were still uncertain whether the infection was due to his foot or his liver and they were still exploring both possibilities.
34. On 28 April 2022 the clinicians identified that the X-ray of 26 April 2022 did not capture the part of Mr Y’s foot where the ulcer was present and performed a further X-ray. This X-ray focused on the ulcer and revealed a pathological fracture (a type of fracture that occurs when underlying disease weakens the bone) in Mr Y’s heel bone that was likely to be due to osteomyelitis.
35. The Trust performed a further X-ray on 29 April 2022 which was reported as ‘highly suspicious for underlying chronic osteomyelitis’. The records indicate the Trust clinicians understood at this point that the infection in Mr Y’s heel was likely ‘calcaneal’ (relating to the heel bone), or osteomyelitis. It is at this time the Trust proposed surgical intervention to amputate Mr Y’s foot.
36. Our podiatrist adviser said the records indicate the Trust did not assess and investigate Mr Y’s diabetic foot ulcer in line with the NICE diabetic foot guidance after the wound began to change and deteriorate from 21 April 2022. Our podiatrist adviser also said if the appropriate investigations had been carried out after this point it is possible Mr Y’s outcome may still have been the same.
37. Our physician adviser said if the Trust had performed an MRI scan on 22 April 2022 it may have been able to confirm a diagnosis of osteomyelitis at this time. However our physician adviser also said there is no evidence to indicate earlier diagnosis would have changed the management of Mr Y’s condition.
38. The NICE diabetic foot guidance says clinicians should:
‘Start antibiotic treatment for people with suspected diabetic foot infection as soon as possible. Take samples for microbiological testing before, or as close as possible to, the start of antibiotic treatment.
When choosing an antibiotic for people with a suspected diabetic foot infection take account of:
• the severity of diabetic foot infection (mild, moderate or severe)
• the risk of developing complications
• previous microbiological results
• previous antibiotic use
• patient preferences.’
39. The NICE diabetic foot guidance provides a list of appropriate antibiotic medication but this list is not exhaustive and the guidance says other antibiotics may be appropriate based on microbiological results and specialist advice.
40. The Trust started treatment with antibiotics immediately after Mr Y arrived at hospital on 19 April 2022. The Trust sought advice from its microbiology team on 20 April 2022 and on the basis of the advice provided, continued to treat Mr Y with antibiotic treatment throughout this admission. Regrettably Mr Y’s infection did not improve despite the treatment.
41. We carefully considered Mrs Y’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We found there was a delay in the Trust diagnosing the infection in Mr Y’s heel and it missed opportunities to carry out investigations which may have enabled diagnosis sooner.
42. We acknowledge the Trust was considering alternative sources of infection during this time, however it is clear from the information in the records Mr Y was a high risk patient and the indications of infection were evident sooner and not appropriately acted upon.
43. In line with the NICE diabetic foot guidance we think the Trust should have performed a further X-ray on 12 April 2022 before discharging Mr Y home. We think the Trust should have performed an MRI following the X-ray of 22 April 2022 as the X-ray was not conclusive and the Trust clinicians suspected infection in the bone of his heel at this time. We think the X-ray of 26 April 2022 should have captured the area of the ulcer and the heel bone. We also think the Trust should have identified the X-ray of 26 April 2022 did not capture the affected area sooner.
44. We think the Trust would have been better informed and able to identify the infection in Mr Y’s foot sooner if it were not for the failings we have identified in the diagnostic pathway. Despite these failings, we have not seen any evidence which would indicate his management and treatment would have been different if the Trust had diagnosed the infection in his heel sooner or that the amputation of his foot could have been prevented.
45. This is because Mr Y was being treated with antibiotics in the community from the district nurses before his admission to hospital on 28 March 2022 and antibiotic treatment continued during his admission. The Trust also provided antibiotic treatment following his admission on 19 April 2022. Sadly Mr Y’s infection progressed despite the antibiotic treatment he received in the community and in hospital and for this reason a definitive solution was required.
Discharged without a catheter on 23 December 2022 46. Mr Y had a history of urinary retention and a catheter (a flexible tube that is used to empty the bladder and drain urine into a bag) was put in place during his admissions to hospital in 2022. Mrs Y says the Trust discharged her husband without a catheter in place on 23 December 2022. She says this contributed to the kidney failure that caused his death in January 2023.
47. The NMC Code says nurses must work with their colleagues to preserve the safety of patients receiving care. The NMC Code also says that nurses must make accurate records at the time of completing an intervention, or as soon as possible afterwards. They must also be candid when a mistake has occurred and take action to put this right as soon as possible.
48. The records indicate Mr Y had several previous unsuccessful attempts at trial without catheter (TWOC) and was unable to adequately pass urine without a catheter in place. The records indicate the Trust referred Mr Y to a TWOC clinic in the community to see if he could manage without a catheter after he was discharged from hospital on 23 December 2022.
49. The records provide no evidence of a documented plan to remove his catheter prior to discharge and the nursing notes and the discharge summary make no reference to his catheter being removed. The nursing notes and discharge summary also make no reference to Mr Y’s catheter remaining in place prior to being discharged home.
50. On the balance of probabilities, we currently think it is more likely than not the catheter was removed before discharge but was not accurately documented. The records clearly state that he did not have a catheter in place when he was readmitted to hospital on 26 December 2022. It is also clear from Mrs Y’s account that her husband did not have a catheter in place when he arrived home on 23 December 2022.
51. This was a specific point Mrs Y raised with the Trust when her husband was readmitted on 26 December 2022 and one which is clearly recorded in the note of the discussion she had with the Trust’s clinical nurse specialist (CNS) on 27 December 2022. At this time the CNS said they could not explain when or why the catheter had been removed and recommended Mrs Y raise this with the Trust’s Patient Advice and Liaison Team to investigate.
52. In its complaint response the Trust said it is unable to establish when or why the catheter was removed as the staff involved in Mr Y’s care cannot remember and it is not evident in the records. The Trust has apologised that this occurred and for the distress it caused. It also said it has taken action to discuss this incident with the nursing team to ensure all interactions are accurately recorded.
53. The records indicate Mr Y was reviewed at 2.11pm by the nursing team before he was discharged on 23 December 2022. The note of this review states ‘stoma bag changed. 550ml. cannula removed.’ Our nurse adviser said the reference to 550ml would not refer to the stoma bag as this is not how the contents of a stoma bag are measured and it is more likely that this was a reference to the amount of urine in his catheter bag.
54. It is possible the nurse erroneously documented removing a cannula, instead of accurately recording they had removed his catheter at this time. It is also possible the nurse removed the catheter and did not record it. It is unlikely we will ever know for certain what happened, but these seem the most likely explanations.
55. We also considered whether there is any other possible explanation for Mr Y’s catheter no longer being in place at this time. Our consultant adviser said a catheter can only be removed if:
• it is removed by a medical professional • the balloon in the bladder (holding the catheter in place) burst • the patient forcibly removes it themselves.
56. Our consultant adviser said a catheter balloon bursting is so rare they have never seen it happen in decades of clinical practice. Our consultant adviser also said if a patient removed a catheter themselves it would cause injury and there is no evidence of such injury when Mr Y was readmitted to hospital on 26 December 2022 or in Mrs Y’s account of his condition whilst at home.
57. Therefore, on the balance of probabilities, we think it is more likely than not the catheter was removed by a nurse before Mr Y was discharged home on 23 December 2022 and poorly documented in the records. We cannot explain why this happened, or whether the nurse realised it was an error. Based on the evidence we have seen so far we think this action was not in keeping with the NMC Code.
58. We asked our consultant adviser whether removing the catheter could have contributed to or caused Mr Y’s death from kidney failure two weeks later. Our consultant adviser reviewed Mr Y’s blood tests from 22 December 2022 and compared them to his blood tests on 26 December 2022 after the three days at home without a catheter.
59. Our consultant adviser said the key indicators for kidney function are creatinine and estimated glomerular filtration rate (eGFR) levels. Creatinine is a waste product that is removed by the kidneys, and a higher number reflects a deterioration in kidney function. The eGFR level is an overall approximation of kidney function based on the creatinine level. The lower this number is, the worse a person’s kidney function.
60. Mr Y’s creatinine level on 22 December was 154 micromoles per litre (μmol/L). His eGFR level was 37. Our consultant adviser said this indicates his kidney function was already impaired at this time, which the Trust clinicians were aware of.
61. Between 23 and 26 December 2022, Mr Y passed very little urine according to Mrs Y’s account. The ambulance records for 26 December 2022 state she told the ambulance crew he had only passed 300ml of urine during the three days he was home. Our consultant adviser said this is a very low amount of urine for such a period of time.
62. The records indicate by 26 December 2022 Mr Y’s creatinine level had increased to 401 μmol/L and his eGFR had reduced to 12. This indicates a significant deterioration in his kidney function during the period he was at home. Our consultant adviser said the records indicate Mr Y was in kidney failure when he attended the Trust’s ED on 26 December 2022.
63. Our consultant adviser said creatinine levels take time to rise, and the period of days Mr Y was unable to adequately pass urine at home is consistent with his kidneys beginning to stop working effectively. Our consultant adviser said the most likely explanation for this deterioration in kidney function was Mr Y being unable to pass urine whilst there was no catheter in place. Our consultant adviser said the records support the view the Trust discharging Mr Y home without the catheter in place was a significant factor in why he had to be readmitted to hospital a short time later with kidney failure.
64. After he was readmitted on 26 December 2022, Mr Y’s condition did not improve despite the Trust reinserting his catheter allowing him to pass urine and despite the further care and treatment the Trust provided for his overall poorly condition. The records indicate the Trust clinicians identified he was approaching the end of his life at this time and Mr Y sadly died on 3 January 2023.
65. Our consultant adviser said if the catheter had remained in place it is possible Mr Y may not have required readmission to hospital on 26 December 2022 and may not have died when he did. However it is clear Mr Y had several complex medical conditions, including chronic kidney disease and general poor health and his condition did not improve despite the treatment provided by the Trust.
66. The records indicate Mr Y was very unwell during this period. Our consultant adviser said it is not possible to speculate as to how long Mr Y may have lived if the catheter had remained in place and it is possible he may have suffered a deterioration in his condition at this point, or at any point during the days that followed, due to his significant health problems.
67. We carefully considered Mrs Y’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We think it is possible Mr Y may not have died on 3 January 2023 if his catheter had not been removed prior to discharging him home on 23 December 2022.
68. We cannot say how much longer Mr Y may have lived as he was very unwell at this time due to his numerous significant health conditions. We also cannot say that his death was something that could have been prevented as his health conditions were chronic and did not improve with treatment after he was admitted to hospital. This has left significant doubt how long Mr Y may have lived if he had been discharged with a catheter in place which we cannot now resolve. This has and will continue to cause Mrs Y considerable distress and is a very serious injustice.
Complaint handling
69. The PHSO principles state public bodies should demonstrate good complaint handling by:
• Getting it right • Being customer focused • Being open and accountable • Acting fairly and proportionately • Putting things right • Seeking continuous improvement
70. Mrs Y says the Trust’s podiatrist admitted to her that they missed the infection in her husband’s foot. She says the Trust refused to say whether this happened in its complaint response.
71. The Trust complaint response says:
‘There was clearly a change in his condition between 21 and 25 April. However it is not possible to say that (the podiatrist) should have debrided the foot on 21 April based on the information available at that time. Foot infections can develop very quickly and debridement leads to its own risk of sepsis as the process involves creating an open wound that leaves bone exposed.
Our podiatrists impression on 21 April was that the heel was dry, there was no obvious infection and it was safer to leave the skin cap on his heel intact. The heel was clearly much worse on 25 April 2022’.
72. We cannot comment on what the podiatrist told Mrs Y. The Trust response is consistent with the evidence in the records and we have said as much in our report about the appearance of the ulcer during this period. Our view is the diagnosis of infection was delayed due to inactivity and inadequate investigations, not that it was clear and obvious but missed by the Trust podiatrist. We do not consider the response provided by the Trust to be a failing in complaint handling and we think the Trust’s response is consistent with the PHSO principles.
73. Mrs Y says the Trust did not provide a satisfactory response to her complaint about her husband’s catheter care. In its response to Mrs Y’s complaint about why her husband was sent home without a catheter in place the Trust has acknowledged its investigation into this point was hindered by poor record keeping by the clinicians at the time. It has acknowledged it could not establish when or why the catheter was removed and has apologised for the distress this has caused. The Trust has taken action to reduce the risk of such incidents happening again in future.
74. When bringing her complaint to us Mrs Y asked us to consider the impact this had on her husband’s condition and outcome and we have provided our view on this above. Although we think the Trust needs to take further action following our investigation, we do not think the Trust’s complaint response was not in line with the PHSO principles given the complaint made and the evidence available. We do not consider the response provided by the Trust to be a failing in complaint handling.