16. Ms X’s overarching concern is that, if not for failings in care, her father could have recovered from his illness and been discharged home. She cites how it had been possible to manage previous skin ulcers. She says her father should have been given broad spectrum antibiotics from the outset, that his cellulitis was misdiagnosed as a deep tissue injury, and mismanagement of his wounds led to significant avoidable suffering and blood loss.
17. Regarding later changes in his condition and his eventual death she says these were avoidable with albumin infusions, better wound management, and interventions to manage her father’s heart failure. She says he did not develop pneumonia, and this was in fact misdiagnosed fluid overload in the lungs. We noted that Ms X provided a significant amount of analysis of her father’s clinical information to support her views. We therefore asked our advisers to review this and provide an overview.
18. Our physician adviser noted that, by Ms X’s own admission, and corroborated by other evidence, Mr Y was a frail elderly gentleman, aged 86 years, with vascular dementia, insulin treated diabetes, hypertension, chronic kidney disease, coronary artery disease and severe pressure ulcers. They said available records suggest that he was immobile with a high degree of dependency and fully dependent on others for his daily care needs. They also viewed the images detailing the severity and extent of his pressure ulceration to inform their view. (Our TVN adviser also reviewed these, and we provide more detail of their advice later in this report).
19. In our physician adviser’s view, they felt it is clear that managing Mr Y’s health should have been considered in the context of his severe frailty. They explain this would mean that individual guidelines for managing single organ disease would not necessarily be applicable. The principles of care in NICE guideline NG56: ‘Multimorbidity: clinical assessment and management’, and GMC ‘Treatment and care towards the end of life: good practice in decision making’ would take precedence.
20. NICE NG56 outlines some specific principles outlining the need to consider, ‘when offering an approach to care that takes account of multimorbidity, focus on: How the person’s health conditions and their treatments interact and how this affects quality of life... the benefits and risks of following recommendations from guidance on single health conditions... improving quality of life by reducing treatment burden, adverse events, and unplanned care.’
21. The GMC guidance outlines in Section 40 Weighing the benefits, burdens and risks: ‘The benefits of a treatment that may prolong life, improve a patient’s condition or manage their symptoms must be weighed against the burdens and risks for that patient, before you can reach a view about whether it could be in their interests. For example, it may not be in a patient’s interests to provide potentially life prolonging but burdensome treatment in the last days of their life when the focus of care is changing from active treatment to managing the patient’s symptoms and keeping them comfortable.’
22. These guidelines would override guidance for specific conditions, which may be appropriate for a patient who only had that condition to treat. This consideration would apply in situations where invasive interventions would only prolong the patient’s suffering with little realistic benefit. Our physician adviser’s view this was Mr Y’s situation, and his death was sadly inevitable and not preventable considering his condition upon admission.
23. We can see Mr Y was suffering under a significant burden of disease. Ms X had concerns about his care and a lack of TVN input prior to his admission. We can understand why she was anxious for him to be seen as soon as possible once he was in hospital.
24. Our physician adviser said he would be considered as someone at the end of life, as defined in the GMC guidance a person likely to die within 12 months. Sadly, the picture is of a patient who no longer had the physical reserves to stave off illness. His impaired skin integrity was leading to progressively more serious episodes of skin breakdown, and this final episode appears to have triggered a cascade of problems he was unable to survive. The focus of care and treatment would, therefore, be guided by principles of managing multimorbidity and a focus on quality of life.
25. There is a significant gap between this view and Ms X’s. We agreed to consider eleven specific points in her father’s care to help us form a view on whether there is evidence of failings that could have affected the outcome for him, or not. We consider each in turn below.
Infection markers were present in her father’s blood results upon admission, but the Trust failed to give antibiotics and fluids to address the risk of sepsis until much later 26. Mr Y’s blood tests on admission showed a White Cell Count (WCC) of 23.7 and C-Reactive Protein (CRP) of 239. These blood markers indicated an infection, although neither is specific as to where the infection is within the body.
27. The Emergency Department sepsis screen was negative, so there was no evidence to prompt clinical concern of sepsis. Mr Y had a NEWS score of 1 on arrival and this remained between 0 and 2 on the first day. This indicates a low risk of deterioration at that time.
28. Mr Y was reviewed by the medical team at 6.16pm. Our physician adviser said the records show a thorough consideration of the presence of infection and its possible origin (such as chest, urine, and skin/pressure sores). Antibiotics were started after this review, at 7.35pm, to treat infected pressure sores. He was treated with IV flucloxacillin. 29 hours after admission his antibiotics were changed to co-amoxiclav the second line antibiotic (to be used when there are indications the first line option is not effective).
29. Our physician adviser said this is fully in keeping with the following NICE and CREST guidance: • NICE CG179: ‘Pressure ulcers: prevention and management’ • NICE CKS ‘Cellulitis - acute: Prescribing information’ • NICE CKS ‘Pressure ulcers: Scenario: Management of pressure ulcers’ • NICE CKS ‘Cellulitis - acute’ • CREST ‘Guidelines on the Management of Cellulitis in Adults’
30. Based on this we did not find indications of failings in the initial management of Mr Y’s infection. The provision of fluids and antibiotics within a strict one-hour timescale is a requirement of the sepsis protocols outlined in NICE NG51. He did not have any clinical indications of sepsis, so sepsis protocols would not be required. He received the appropriate type of antibiotic within a reasonable timescale.
31. We appreciate Ms X wanted her father to be placed on broad spectrum antibiotics as early as possible to remove any possibility that he had an infection resistant to the more targeted ones he was initially given. This would have been against guidance to do before trying the first, and second, line options, and we have seen no indication these did not start to address the infection.
32. Based on this, our current view is there is no indication in the evidence we have seen that his infection markers were not noted, considered, and acted upon in a reasonably timely manner.
Staff did not give her father albumen despite his low levels 33. Mr Y had chronically low albumin levels upon admission. Albumin is a protein found in blood plasma which helps retain water in the blood vessels of the body. Ms X says an infusion of albumen would lock fluid into her father’s bloodstream and prevent it pooling in his tissues, which she says increased his risk of heart attack etc. Albumin is not usually given except in intensive care. We note Mr Y was considered unsuitable for placement in intensive care due to his advanced frailty and multiple comorbidities.
34. Our physician adviser explained that this low albumin level was likely to be multifactorial (due to many reasons) and reflect Mr Y’s advanced frailty and comorbid conditions (suffering multiple diseases or conditions at the same time). In this context it is not simply that a person lacks albumin and requires replacement. The low albumin in this case reflects poor nutrition, frailty, the presence of infection and inflammation.
35. NHS Scotland NPPEAG ‘Clinical guidelines for Human Albumin Use’ would be relevant for Mr Y’s situation. These outline specific clinical scenarios where human albumin solution (HAS) is indicated to be used, none of which were relevant to Mr Y’s situation according to our physician adviser.
36. Regarding volume expansion (increasing Mr Y’s blood volume to help with circulation and oxygenation), which our physician adviser says was relevant here, the guidance states: ‘Volume expansion – Synthetic alternatives or Saline 0.9% may be used for temporary intravascular volume expansion. No studies have convincingly shown that 5% Albumin confers any survival advantage.’
37. It is established that Mr Y did have low albumin levels upon admission and was not given albumen infusions. Our physician adviser explained this reflected his chronically poor condition rather than a temporary issue that could be resolved with supplementation. As giving him HAS would have not been in line with guidance, and all indications are there would be no increased chances of survival from doing so, we found this would have been difficult to clinically justify doing and was not a failing.
Staff lost a wound swab which delayed identifying the type of infection her father was suffering 38. Mr Y’s records show a sacrum wound swab was taken at 12.19am upon admission but not processed due to a labelling omission. This does not indicate a lost swab but potentially a delay getting a result. Later swab results from 27 December show a result of ‘Mixed Coliforms ++ Enterococcus faecalis ++ Anaerobes NOT isolated’. The labelling issue appears to be an individual error, but it is reasonable to assume if not for the error it may have been possible to know this result earlier.
39. Our physician adviser said this result did not yield any significant new information that would influence Mr Y’s treatment. Considering that he was provided with the correct antibiotic treatment in line with the standards set out in earlier in this report, according to the advice we have on his initial admission, this appears to the case.
40. There is evidence of a swab being mislabelled, and so not processed, but not lost. This is not ideal but not so serious as to be considered a failing if there is no significant impact. This can happen in a busy clinical environment and the advice we have says this would not have significantly influenced Mr Y’s care. As such we did not find a failing on this point.
When her father was given antibiotics, these initially were the not the correct type to treat his infection of cellulitis 41. The initial antibiotic used from the Emergency Department was intravenous flucloxacillin. This would be a standard antibiotic to use in this scenario of infection of pressure ulcers. This suggests they were the correct type in line with NICE NG141 ‘Cellulitis and erysipelas: antimicrobial prescribing’.
42. The advice from our physician adviser confirms this was the correct type of antibiotic to treat cellulitis. They said the rationale for the first line antibiotics was sound and supported by national guidance as set out earlier in this report, as was an escalation to second line when Mr Y showed signs of worsening infection on 21 December.
43. The first and second line antibiotics prescribed followed the principles of antimicrobial stewardship and prescribing as in the below three guidelines: • NICE NG15: ‘Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use’ • BNF ‘Antibacterials, principles of therapy’ • DHSC ‘Antimicrobial prescribing and stewardship competency framework’
44. Based on the above we are not seeing evidence of the incorrect types of antibiotics being used initially. Furthermore, these were changed to a second line antibiotic in response to Mr Y’s change in condition. As this use of antibiotics was in line with several guidelines we found no indication of any failing in the use of antibiotics to treat Mr Y’s cellulitis infection.
The Trust failed to involve the tissue viability team soon enough despite her requests 45. Mr Y’s medical records show clear notes detailing her request for TVN input at the outset of her father’s admission on 20 December 2022. They also detail how she had been trying to get him seen by a TVN in the community and had been unhappy with a lack of TNV input which was, in her view, urgently overdue. While we are not looking at the care prior to his admission, we can understand how this caused her such worry. It also provides evidence of the Trust noting her requests and why she was so concerned about this point.
46. We note Mr Y was admitted on a Friday. The medical team recognised the need to refer him to the Tissue Viability Team, but it also was aware that there was no availability for that service at the time, until the next working day (Monday 23 December). Input was instead obtained from Plastic Surgery team and a care plan put in place until a TVN was available on 23 December. Mr Y was seen and reviewed by a TVN on that day.
47. Therefore, we see that this was the earliest opportunity to obtain input from a TVN. The wait was due to the timing of his arrival and the availability of resources, and not any unwillingness or lack of proactiveness on the part of the treating medical team.
48. Our TVN adviser said the Trust involved the Plastic Surgery team very promptly (he was seen on the day of admission) and the Tissue Viability team reviewed Mr Y on the next working day after admission (23 December 2019). They said the Plastic Surgery team put an appropriate plan of care in place.
49. Mr Y was recognised as being unsuitable for surgical intervention and management with dressings and continuation of his medical treatment (antibiotics etc.) was planned until the Tissue Viability team was able to contribute further advice. We did not identify any concerns about the initial management of his wounds once the TVN was able to assess him on 23 December.
50. Our TNV adviser noted it was acknowledged by the medical team from the outset that TVN input was needed. Also, they explained there are no specific national standards associated with tissue viability referral timeframes. In the absence of a specific standard, it is their view that Mr Y was referred within an appropriate timeframe.
51. As TVN input was not immediately available due to the weekend starting, we see Plastic Surgery input was sought immediately instead. As the plan of care appropriate according to our TVN adviser, and TVN input was provided at the earliest opportunity after that, we can’t say it was not done soon enough, or identify any impact from the wait.
52. It is apparent Ms X was asking for TVN input from the outset and the Trust agreed with her. We therefore cannot see evidence of her requests being ignored. We did not find evidence of the Trust failing to involve a TVN soon enough or the Trust not heeding Ms X’s requests.
The Trust misdiagnosed the cause of his buttock wounds as deep tissue injury when it was necrosis due to untreated cellulitis 53. Our TVN adviser reviewed photographs taken of Mr Y's wounds at the time of his admission. They said it is difficult to conclude from these that he had suffered just deep tissue damage. They noted an unstageable(necrotic) pressure ulcer in reasonably close proximity to the new area of concern (which was subsequently identified as a DTI). They concluded the pressure ulcer may have been the likely source of cellulitis infection.
54. Our TVN adviser explained that it is difficult to identify between deep tissue damage and cellulitis on the available photographic evidence alone. However, the additional documentation in the medical records supplied provides more information. These document that the wound area was palpated by a doctor who was also able to see the skin at the time. The doctor described the wound as deep tissue damage. We see that the doctor was able to examine the skin at first hand and not base their view on pictures only.
55. European Pressure Ulcer Advisory Panel (EUPAP) guidance defines deep tissue damage as: ‘Purple or maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution (breakdown of the skin) may be rapid exposing additional layers of tissue even with optimal treatment.’
56. As described above, deep tissue damage can further evolve and breakdown to necrotic tissue. The description in the records describes a red area towards the Mr Y’s hip treated with antibiotics. While we recognise Ms X disputes this was the case, our TVN adviser noted that later photographs indicate the area of redness had reduced over time. They said this indicates evidence the antibiotic treatment working to clear the infection. We think it unlikely that this improvement would have happened if antibiotics were not provided and providing some benefit.
57. Despite this, a necrotic wound developed as Mr Y’s tissues had already sustained damage. Our TVN adviser said this is likely to have stemmed from a combination of cellulitis and deep tissue damage. Throughout this initial period there is reference in the clinical records of antibiotics being prescribed. On balance, we see there is no evidence to suggest that cellulitis was left untreated.
58. There are a number of further entries in the clinical records that continue to describe the area as deep tissue damage. As set out elsewhere in this report our TVN adviser noted Mr Y was treated for cellulitis. As such, it is likely he suffered a combination of cellulitis and deep tissue damage initially. The buttock site was ulcerated and a likely site of cellulitis infection, and the hip area was reddened and, while the skin was not initially ulcerated, suspected of showing early signs of a DTI prior to admission.
59. We note that later these two areas combined, as the buttock wound progressed to a DTI as well. We see Mr Y had both a DTI and cellulitis, and he suffered necrosis due to a combination of these, despite evidence of antibiotic treatment being effective. As there were already signs of a DTI present on his hip upon admission, before there was any opportunity to provide treatment, it is more likely than not that the tissue damage that led to necrosis had already occurred.
60. We found no evidence of the Trust misdiagnosing of Mr Y’s buttock wound as a DTI. This was identified as an area of ulceration affected by cellulitis initially and treated appropriately. He also had a hip wound suspected to be a DTI upon admission. We can understand how this may have concerned Ms X as the buttock area was then treated as a DTI later, but the evidence supports this as being recognised as a cellulitis site initially and addressed as one at the outset of her father’s admission.
Staff failed to act upon signs his condition was deteriorating (high temperature) quickly enough and change his antibiotics to broad spectrum types 61. As set out earlier in this report, Mr Y was initially placed on flucloxacillin ( then changed to Co-amoxiclav) antibiotics, which is the appropriate treatment for cellulitis infection. Ms X says this was inadequate and her father should have been placed on stronger, broad spectrum, antibiotics at an earlier point.
62. Our physician adviser said that there was no clinical indication for an escalation in antibiotic treatment until Mr Y’s clinical condition deteriorated in the early hours of 8 January 2020. They also note that the day before he had shown signs of improvement as the clinical notes state he was ‘more reactive, eating well… improving CRP’. We see that this indicates the initial antibiotic regime (and other treatment) had started to have a beneficial effect.
63. On 8 January Mr Y’s NEWS rose to 5. This indicates an acute change in his condition, he had respiratory signs on examination (tachypnoea – a fast breathing rate, reduced oxygen saturations, thick white respiratory secretions and a cough). He was now clinically suspected to have developed hospital acquired pneumonia (HAP). Our physician adviser said there was no indication to treat HAP until these signs developed.
64. From this point his antibiotics were changed, on the advice of the microbiology team, to Tazocin (1st dose on 8 January). Vancomycin and a dose of Amikacin were introduced following another deterioration on 9 January in view of the suspicion of the development of HAP. This is the point where stronger broad spectrum antibiotics were introduced.
65. What we found is that Mr Y was receiving continuous antibiotic therapy escalating to stronger broad spectrum antibiotics later. He was already on antibiotics when he developed HAP which were having some effect on his primary infection. We see that there were several types of different infections he was contracting so moving to antibiotics that could treat a wider range of bacteria was appropriate.
66. According to the advice we have obtained there would be no clinical indication to change this regimen until his new HAP infection on 8 January 2020. This is when his antibiotics were change in response to microbiology advice, we found there is no indication of the medical team not acting quickly enough to Mr Y’s deterioration in condition.
Staff failed to provide appropriate treatment following her father’s heart attack prior to debridement attempts and did not follow advice from the cardiologist 67. Mr Y had pre-existing heart disease. He had an episode of appearing unwell (reported to appear sweaty and clammy) 4 January 2020 following his admission. An Electrocardiogram (ECG) report showed no new changes in his heart that might indicate a heart attack. A blood test showed raised basal natriuretic peptide (BNP), which indicates worsening heart failure.
68. Our physician adviser says this is, therefore, not suggestive of a new cardiac event. They note serial troponin (a protein released into the blood when heart tissues are damaged) tests showed elevated levels. They said, in the context of kidney disease and severe inflammation/infection, these were not definitively diagnostic of a heart attack, although they were treated as such by the medical team.
69. The Trust took advice from a cardiology specialist on management. Ms X is unhappy this advice was not followed. Our physician adviser said the medical team, with knowledge of Mr Y’s comorbidities, needed to consider this advice (which would be specifically focused on heart management), and then apply it appropriately.
70. Our physician adviser said invasive treatments (such as procedures to open up blocked arteries) were neither indicated, nor suitable, for a person of Mr Y’s frailty. Use of stronger blood thinning medications (in addition to aspirin which he was already taking) would be contraindicated due to his other conditions. This is due to Mr Y having a significant bleeding risk alongside anaemia which was already present.
71. A further echocardiogram test was recommended, but our physician adviser said this would not be expected to influence Mr Y’s management. They said it would be an unnecessary test to go through. Although an echocardiogram is non-invasive, they explained that such a test would still come with some discomfort, and require body positioning, which may have been problematic for Mr Y considering the extent of his pressure ulcer wounds.
72. Our physician adviser notes that careful fluid management was required, due to Mr Y also receiving intravenous antibiotics and him developing high blood sodium levels. He had also lost a lot of fluids from his wounds (which each would require replacing). They reiterated that an echocardiogram test is not essential to manage heart failure and would not be expected to influence treatment in this scenario. Treatment would be based on clinical findings, observations, and symptoms.
73. Nonetheless we see it would be a difficult balancing act in Mr Y’s case. He needed, for example, to receive fluids in order to address certain problems, but fluids would also worsen other problems (for example his heart failure would respond poorly to this and increase strain on his heart). We see that interventions which may have been only beneficial for a patient needing one condition treating could have caused him harm by worsening others. This would greatly limit the options available to manage his care.
74. Our physician adviser stressed that managing heart failure would require care, taking into account Mr Y’s many comorbidities and acute medical problems. They said a holistic approach would be indicated, as outlined in the NICE guideline NG56: ‘Multimorbidity: clinical assessment and management’, and GMC ‘Treatment and care towards the end of life: good practice in decision making’. This was, in their view, the appropriate route to take and that the care provided was in line with these guidelines.
75. Considering the above advice, it is apparent that recommendations from the cardiology specialist were not fully applied. It is understandable why this would concern Ms X. However, there appear to be good reasons why the advice needed to be considered and applied in the context of her father’s specific needs.
76. A such, we found the cardiology advice was correctly viewed by the medical team as presenting options, not instructions, to the medical team responsible for his overall care. This was the right thing to do in the circumstances as he had many, sometimes conflicting, needs as his health failed and it was the responsibility of the medical team to balance advice from many different medical specialisms.
Staff took the wrong approach with wound management and debridement and should have persevered with hydrogel treatment 77. Ms X’s says she witnessed the towel used during her father’s debridement procedure becoming soaked with blood. In her view this was an unnecessary procedure and led to her father suffering significant blood loss and this contributed to his cardiac event. The Trust response says the fluid soaking the towel was a combination of Mr Y’s hydrogel dressings, necrotic tissue and wound exudate (fluid leaked from blood vessels into a wound site as part of the body’s natural healing mechanism).
78. In order to form a view on this we asked our TVN adviser. They noted Mr Y was treated with a combination of dressings (to support autolytic debridement) and conservative sharp debridement (removing the outermost necrotic tissue with a scalpel) was also utilised.
79. Autolytic debridement is a method of wound care that uses the body's own enzymes and moisture to liquefy dead or necrotic tissue. This process is the slowest method of removing dead tissue usually used in long-term care settings. It involves keeping wound fluids in constant contact with the wound, typically such as hydrogels (used in Mr Y's case). These do not damage healthy skin as it promotes healthy tissue growth while breaking down non-viable tissue over time.
80. This is in line Medetec Publications: ‘Surgical dressings and wound management’ guidance. Evidently this was a suitable approach to take (and Ms X does not disagree) but we note it is best suited to long term care settings. Mr Y was considered to be approaching end-of-life stage. He was suffering under the burden of multiple conditions, including fighting off an infection, and was very frail.
81. Our TVN adviser also noted that on 22 December Mr Y’s inflammatory markers were worsening despite antibiotic treatment (this improved later) and there was a concern he may be developing an abscess under the skin in the area of his DTI. Discussions between the Plastic Surgery and Medical consultant show a plan to do an ultrasound to establish if there was an abscess and considering options to drain this if this was the case.
82. Mr Y was also not considered suitable for surgical debridement due to his very poor condition and multiple health problems upon admission as he would not be expected to survive this. A further review from the Plastic Surgery team set a plan for Mr Y to receive bedside conservative debridement and noted his antibiotics had been changed.
83. On 23 December Mr Y was reviewed by the Plastic Surgery team again. The appearance of his DTI site now was discoloured with a blue tinge. This is associated with circulation loss which would indicate the start of necrosis under the skin. A further review by the TVN and Plastics team noted the pressure ulcer on his buttock, DTI on his hip, and that his skin integrity was deteriorating. A treatment plan was set to continue with hydrogel dressings for the pressure ulcer.
84. Our TVN adviser was slightly critical of the level of documentation on the following days. They noted that records for 27 December document that hydrogel was used for this period, so this is not necessarily a failing as it is possible to establish the treatment was in line with his care plan.
85. Our TVN adviser then noted that, by 27 December, there had been some improvement to a foot ulcer and that the Plastics Team attempted bedside debridement on Mr Y’s pelvic wounds to remove the top layer of dead tissues that had built up from the use of hydrogels in the preceding days. This is in line with Wounds UK ‘Consensus guidance for the use of debridement techniques in the UK.’ This requires access to debridement be based on clinical need, and that sharp debridement can be completed at the bedside by a clinician that is trained in the procedure.
86. Mr Y’s ultrasound thankfully established there was not an abscess under his skin, but there was an oedema (an accumulation of fluid in the tissues) in the area of the DTI. The TVN provided advice on the phone that they were happy with his wound management plan and so did not need to review Mr Y again at that time. This does not indicate any concern from the TVN’s perspective about the management of his wounds or the outcome of the sharp debridement.
87. Our TVN adviser notes there is photographic evidence that the black necrotic tissue was softening by using this combination of autolytic and conservative sharp debridement. They explained that any debridement of a wound will potentially make a wound look worse initially whilst it is going through the debridement phase. This will reveal the underlying damage once cleansed of devitalised tissue as outlined in Wounds UK ‘Living day-to-day with a heavily exuding wound: Recommendations for Practice’.
88. Our TVN adviser explained that consideration for debridement of wounds is an essential element of good wound management. Often necrotic tissue can harbour bacteria and act as a barrier to healing. Mr Y was suffering from cellulitis as well as necrosis so we see that infection management would be a high priority and removal of any dead tissue vital to reducing the risk of his infection getting worse.
89. They said throughout this period of care Mr Y was regularly assessed and reviewed by the TVN service and the plastic surgical team. Concerns were escalated with regard his management plan to a consultant, and decisions were made based on his clinical presentation including blood results and condition of his wounds. They felt, on balance, the combination of surgical and autolytic debridement under specialist care was an appropriate treatment plan.
90. Based on this, while we can understand Ms X’s alarm at the visible state of her father’s wounds, this does seem consistent with what would be expected to happen to a patient with such extensive necrotising wounds. We have not seen compelling evidence to support the view that there was excessive blood loss or inappropriate management of the wounds.
91. We can also see there was some reasonable justification in attempting conservative sharp debridement. Considering Mr Y had several days of hydrogel dressings encouraging autolytic debridement of any dying tissues prior to 27 December, this would need physical removal. This step had been set out in the plan agreed between the Medical, Plastic Surgery and Tissue Viability teams five days earlier, and in line with several standards on wound management.
92. We also note that sole use of hydrogel for debridement would be a long-term strategy. While we accept that Ms X may disagree, the weight of evidence does suggest an awareness that her father did not have much time left to live. There was an acute need to get his infection under control as soon as possible. Considering the limited options available due to his poor physical condition upon admission, persevering with hydrogel does not appear to be supported by the consensus of a number of experts in wound management.
93. We found no evidence to indicate the approach to wound management was wrong or that persevering with hydrogel would have improved Mr Y’s changes of a better outcome.
Staff misdiagnosed her father as suffering pneumonia when he was suffering from congestive heart failure and fluid retention 94. On 8 January 2020, two days prior to his death, Mr Y’s condition deteriorated. his NEWS rose to 5 indicating an acute change in his condition. He had increased respiration rate, reduced oxygen saturations, thick white respiratory secretions and a cough. He was diagnosed with a right sided hospital acquired pneumonia (HAP).
95. Our physician adviser said this is also evidenced by right sided lung changes appearing on an X-ray and rising WCC and CRP blood markers denoting infection. The chest X-ray was not reported to show any features of heart failure (pulmonary oedema - excess fluid within the lungs) to account for the clinical findings. They said, taking into account his comorbid conditions, recumbency (being nursed in bed), and severe pressure ulcers, that the development of pneumonia during an inpatient hospital stay would not be unexpected. They could not see any indication pneumonia was preventable, nor identify any failings in managing this condition.
96. A medical review dated 9 January outlines Mr Y’s clinical condition, observations and examination findings. This shows the medical team recognised that despite treatment for pneumonia he was critically unwell, and this was communicated to his family at that time.
97. We found the evidence supports a diagnosis of HAP was correct. Also, while Mr Y did have heart failure, but not evidence of pulmonary oedema, we are not seeing evidence of misdiagnosis on this point.
Staff failed to provide appropriate treatment to reduce the pressure on her father’s heart from fluid retention 98. Ms X expressed concerns that her father was pooling fluid in his tissues due to his low albumin (as this would serve to counter pooling by retaining fluid in the bloodstream). She also said her father was given too much IV fluid which caused fluid overload and further stressed his heart.
99. As previously outlined, the use of HAS to increase blood volume and reduce tissue pooling in a patient in Mr Y’s situation would not be in line with guidance. Our physician adviser was clear they would not expect it to be of benefit in Mr Y’s treatment or confer any better chance of survival.
100. Our physician adviser said Mr Y’s fluid balance was managed appropriately. They noted that Mr Y was recognised to have heart failure and low blood albumin from the outset of his admission. They say the clinical records and a chest X-ray do not support that he was experiencing pulmonary oedema (accumulation of excess fluid in the lungs) from fluid overload, and they do support the presence of pneumonia.
101. Our physician adviser explained that NICE multimorbidity guidance is more appropriate to apply in this scenario than single organ guidance. Overall, our physician adviser said that it is clear Mr Y was entering the end-of-life stage at this point due to the number, and severity, of his problems. He had multiple severe necrotic wounds, was in advanced heart failure, had contracted HAP, in addition to his frailty and other chronic health problems.
102. They said he was treated with intravenous fluids at times when this was considered clinically necessary, and the records make clear this was considered carefully. We see IV fluids were not resorted to excessively. They were used to prevent him becoming dehydrated, deliver antibiotics, and address other clinical problems such as high sodium. This was clinically appropriate and while fluid restriction can be beneficial for heart failure in isolation, that approach would be detrimental for his other health problems.
103. Our physician adviser said was it was therefore appropriate to focus on the quality of his remaining time with interventions that would ease his discomfort, rather than attempting interventions which would be likely to cause him more suffering and not prevent the end of his life.
104. What we found is there was no viable solution to managing Mr Y’s heart failure without increasing his suffering and risk of death from another cause. Potentially those other causes would have caused more suffering and granted him less dignity in death.
105. We appreciate that Ms X may strongly feel the focus of care should have been on her father’s heart as the key priority. We cannot say it was wrong to focus more on his comfort levels and symptom control than the risk of fluid overload, as the medical team had a responsibility to act in line with the NICE and GMC multimorbidity principles outlined in paragraphs 22 and 23 of this report.