13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
14. We understand Mrs G has concerns about how the Trust carried out her knee replacement surgery on 21 August 2023. She has concerns about how the procedure was managed post operatively, as she went on to develop infections and sepsis.
15. The Trust says the operation went well, but unfortunately she went on to develop a post operative infection.
16. Our adviser has very carefully considered the preoperative information, operation note and evidence. Mrs G was seen in the preoperative assessment clinic and it was identified she had arthritis of her knee with a valgus deformity. This is a condition where the knee is not straight. It was documented this could be corrected with knee replacement surgery.
17. The NICE guidance covers care before, during and after planned knee replacement.
18. The guidance sets out clinicians should discuss the benefits and risks of the procedure including the possible need for more surgery in the future. The records evidence consent was taken from Mrs G. The consent form shows the risks and benefits were discussed with her. This appears to have been appropriately discussed and considered, and signed by Mrs G.
19. Our adviser explains this was a standard operation, and the evidence supports it was carried out correctly and appropriately using a standard technique and implant. There is no evidence to support this was not carried out in line with the NICE guidance.
20. We recognise Mrs G went on to develop an infection post-surgery and became unwell and can understand why she questions if this was as a result of the initial surgery. We will consider this below.
21. Our adviser explains that unfortunately even with the correct treatment, it is a known risk of complication of any joint replacement surgery that patients can develop an infection, which is what happened in this case.
22. This is documented in Mrs G’s consent form, which explains there is a risk of infection from the surgery. The form highlights a patient will be given antibiotics at the time of surgery in attempt to mitigate this. The consent form explains that despite this, infections still occur, and the wound site may become hot, red and painful. It goes on to say there may also be a discharge, fluid or pus, and this is usually treated with antibiotics, or an operation to washout the joint may be necessary. The consent form says the infection can sometimes lead to sepsis, and strong antibiotics are required.
23. The records show Mrs G was given antibiotics at the time of surgery in line with NICE guidance. Unfortunately following her surgery, she developed hospital acquired pneumonia (HAP) and needed to be prescribed with further antibiotics.
24. This was not an infection of the knee itself or developed as a result of specific care of the knee but is an infection from being in hospital. Our adviser explains anyone who is admitted to hospital is at risk of hospital acquired pneumonia. This is why there is a very fine balance looking to discharge patients when possible, to prevent the risk of infection from being in hospital and deconditioning. Prolonged hospital stays and a weakened immune system can increase the risk of developing this. She was appropriately treated for hospital acquired pneumonia with antibiotics.
25. Mrs G’s knee wound did show some oozing, and as a precaution the Trust then performed an operation (DAIR) on 18 September to wash out the joint and replacement the polyethylene (plastic) component of the joint.
26. During this operation, samples of the tissue from the joint were sent off to the laboratory to check for infection. The laboratory findings confirmed that the deep tissue did not grow any organisms. This was therefore considered to be a superficial infection, rather than a deep infection of the joint.
27. The Trust carried out the correct treatment by performing a washout, replacing the polyethylene and sending the tissue samples to the laboratory.
28. The records suggest on the day of the DAIR procedure, Mrs G was given antibiotics at the start of the procedure, prior to the tissue sampling. Usually, antibiotics would be withheld and given after the tissue has been sent to the lab for sampling. Our adviser explains usually the antibiotics should be given afterwards, to prevent the antibiotics from supressing any growth of any deep tissue organisms which are sent off. There is an indication the Trust got something wrong here.
29. However, our adviser is reassured the procedure was otherwise carried out in line with NICE guidance, and there is no other evidence to suggest Mrs G’s infection could have been avoided. Mrs G went on to make a full recovery from this suggests there was no deep infection.
30. We are mindful that Mrs G did become unwell. We hope we have been able to provide her with reassurance that this is not because she was not provided with the correct treatment, but that these are known risks and complications of joint surgery that sometimes cannot be avoided. Despite this, we do not dispute this was a very difficult experience and we are pleased to learn she went on to make a full recovery.
31. We understand Mrs G has concerns the Trust discharged her on 27 September when she was still unwell, as she had to be admitted again on 30 September. As set out above, discharge is a very fine balance. There can be a risk to a patient staying in hospital leading to further harm.
32. The discharge guidance Annex D lists the criteria to reside in hospital. Generally, if a patient does not meet any of these criteria, there can be an active consideration of discharge. The criteria is listed as: • ‘requiring ITU or HDU care? (intensive care or high dependency unit) • requiring oxygen therapy/NIV? (ventilation) • requiring intravenous fluids?
• NEWS2 greater than 3? (clinical judgement required in persons with AF and/or chronic • respiratory disease) • diminished level of consciousness where recovery realistic?
• acute functional impairment in excess of home or community care provision?
• last hours of life?
• requiring intravenous medication > b.d. (including analgesia)?
• undergone lower limb surgery within 48 hours?
• undergone thorax-abdominal/pelvic surgery with 72 hours?
• within 24 hours of an invasive procedure? (with attendant risk of acute life- threatening deterioration)’.
33. Discharge is a very complex and nuanced process, between a patient needing treatment in hospital and aiming to get them home with the appropriate care and support in place. If a patient remains in hospital, they can become deconditioned and there is a risk of infection.
34. Mrs G’s wound had been leaking post-surgery. The clinicians wanted to stop the leak prior to discharging her. To minimise any infection, as referred to above, the Trust carried out a DAIR on 18 September. She was given antibiotics and the Trust continued to monitor the wound. It was noted this was a superficial infection, meaning this infection is limited to the surface or specific area like a wound, not penetrating deep into underlying tissues. There was not a suggest of an infection deep in the joint.
35. On 19 September the wound was noted to be ‘clean and dry’. On 20 September her National Early Warning Score (NEWS) was 0. NEWS is a standardised system used to asses the risk of patients deteriorating or becoming ill. A score of 0 means there is no signs of acute illness or deterioration. Her dressing was dry, and they were waiting for culture results before deciding on the next steps.
36. On 23 September, the wound had ‘minimal strikethrough’, which meant it was not oozing as much. Mrs G was on antibiotics and her observations were stable. On 25 September, the wound was noted to be dry and healthy. The ward round from 26 September noted Mrs G was well and her NEWS was 0. She was reviewed by the orthopaedic team that day, and on 27 September prior to discharge.
37. The Trust then received Mrs G’s samples from the laboratory. She was prescribed four further weeks of antibiotics. Mrs G had received precautionary treatment for the wound, antibiotics and a plan for follow up care on 10 October. Her observations were stable. Based on all the above, it was safe and in line with the discharge guidance to discharge her at that time.
38. We understand Mrs G went back into hospital with vomiting and a rash a few days later. Our adviser explains this appears to be a result of her being on strong antibiotics, which she needed, and could not have been predicted. It does not appear to be her presenting with any infection in the knee or that anything was missed. This supports it was still appropriate to discharge her in the clinical circumstances.
39. We acknowledge it must have been very worrying for Mrs G to go home and need to return to hospital. With hindsight, we know she went on to need further treatment for a chest infection from being in hospital. Her knee continued to recover well and did not show any signs of infection. The clinical picture at the time was that it was a safe decision to discharge her. We hope this can provide reassurance about why this decision was made.
40. Overall, we have not seen any evidence to suggest any treatment was missed, or that Mrs G’s infections could have been avoided. We are reassured the decision to discharge her was safe and in line with guidance. We were very sorry to learn about the time Mrs G spent in hospital and hope this information has been useful.