16. Prof. A complains that during Dr J’s hospital admission from 29 September to 1 October 2022, the Trust did not identify necrotising fasciitis at the earliest opportunity. He is concerned the Trust did not adequately monitor Dr J’s skin before necrotising fasciitis was confirmed and after the first debridement surgery. He believes staff should have drawn around the rash with a pen to allow them to monitor whether it was spreading. He also believes the surgeons should have given better post-operative instructions to monitor the skin. Prof. A also feels debridement of the skin was not completed adequately and early enough.
17. We have considered the WJES review which sets out recommendations for the management of skin and soft tissue infections. This states ‘Patients with NSTI [necrotising soft tissue infections] usually present with severe pain which is out of proportion to the physical findings. Typical local signs are as follows: • Edema [swelling] • Erythema [a skin condition with the main symptom being a rash] • Severe and crescendo [increasing] pain out of proportion • Skin bullae [large fluid filled blisters] or necrosis (at later stage) • Swelling or tenderness • Crepitus [audible or palpable sounds]’
18. We have also considered Public Health England guidance on the characteristics and diagnosis of necrotising fasciitis, which says:
‘Advanced symptoms (usually within 3 to 4 days) include: • swelling of the painful area, accompanied by a rash • diarrhoea and vomiting • large dark blotches, that will turn into blisters and fill up with fluid
Critical symptoms (usually within 4 to 5 days) include: • severe fall in blood pressure • toxic shock from the poisons released by the bacteria • unconsciousness as the body weakens’
19. When Dr J attended the ED on 29 September, he presented with a variety of symptoms including a six-day history of fever and diarrhoea, urinary incontinence, bruises on his legs, slurred speech, alcohol withdrawal, jaundice for the previous three months, pain and swelling in his left leg and reduced mobility. It was noted he had suffered a recent head injury during an assault and had recently travelled to Singapore and Thailand. On examination it was noted that Dr J had a rash on his abdomen.
20. Dr J was assessed by an ED consultant, who requested appropriate investigations. He was showing signs of possible sepsis and had a National Early Warning Score (NEWS) of 6, indicating he was medium risk in terms of how severely unwell he was and his risk of deteriorating. We understand from our ED adviser that Dr J was managed appropriately, in line with the NICE Surveillance Report. This sets out recommendations for patients with a NEWS of 5 or 6 and includes administering antibiotics, which Dr J was given.
21. The role of the ED includes assessing a patient and, where necessary, referring them to the appropriate team(s), which is what happened in this case. The plan included referral to the infectious diseases team, surgical team and ICU. The surgeon who reviewed Dr J considered there was no convincing evidence of NSTI. The critical care doctor identified Dr J was significantly unwell with the potential to deteriorate further.
22. The ED team noted the presence of the rash and took photographs. There is no guidance on how this type of rash should be documented and monitored or how often.
23. The records show the ED team considered necrotising fasciitis as a possible diagnosis and referred Dr J to the surgical team to rule this out. The initial impression was that Dr J was suffering with alcohol withdrawal and a fever of unknown origin, as the source of infection was not clear. Most importantly, the ED team realised Dr J was very unwell and referred him to ICU, as he needed organ support. After considering the clinical advice and evidence available, our view is that Dr J was managed appropriately while in the ED, in line with GMC Good Medical Practice. This says:
‘15 You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a) 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 b) promptly provide or arrange suitable advice, investigations or treatment where necessary c) refer a patient to another practitioner when this serves the patient’s needs.’
24. Before Dr J was admitted to ICU, he had been reviewed by the ED team, surgical team and infectious diseases team. Each team considered the possibility of necrotising fasciitis, but this seemed unlikely for several reasons according to the advice from our intensive care and surgeon advisers. Firstly, the organisms causing necrotising fasciitis would generally cause gas to be present in the fascial planes within the abdomen. This was not apparent on the CT scan. Secondly, there was no evidence of necrosis (death of body tissue) at the time of Dr J’s admission. Thirdly, Dr J had liver failure and recent trauma which could have accounted for the bruising to the skin. Lastly, there was an absence of severe pain in the area of the rash (with Dr J reporting generalised tenderness on examination). Our intensive care adviser said, although necrotising fasciitis had not been completed ruled out, it is likely that the ICU team considered the risk to be low.
25. With the benefit of hindsight, by the time Dr J attended hospital his condition was advanced/critical, according to the Public Health England guidance. For instance, he had diarrhoea and signs of septic shock. These symptoms could have been related to another condition and Dr J’s skin changes were not advanced, which is partly why the diagnosis was not confirmed straight away.
26. The WJES review highlights the difficulty in diagnosing necrotising fasciitis, stating ‘The initial differential diagnosis between a cellulitis and a necrotizing infection that requires prompt operative intervention may be difficult.’ In Dr J’s case the clinical picture was not initially in keeping with necrotising fasciitis, particularly before his admission to ICU. Our surgeon adviser also explained necrotising fasciitis can be difficult to diagnose because skin changes are often small, due to the infection being under the skin.
27. We consider that after Dr J was admitted to ICU, the nursing team could have taken further steps to monitor Dr J’s skin and done so more regularly, in line with NMC guidance ‘The Code’, which says nurses must:
‘13.1 accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care
13.2 make a timely referral to another practitioner when any action, care or treatment is required’
28. Our nurse adviser suggested the nursing team could have marked the rash with a pen and documented their findings regularly when recording their observations. This could have helped to effectively identify worsening of the rash. While this may have been helpful, there is no guidance for nurses in relation to reviewing and monitoring rashes in cases of potential necrotising fasciitis, and our view is that, overall, the Trust acted in line with the guidance above. Also, our nurse adviser noted the nursing team did take some photographs which is useful as a reference point. Some of the photographs include markings on them, but we note Prof. A says he drew the markings around his brother’s rash.
29. When Dr J arrived on ICU he had been receiving treatment for sepsis and had signs of multi-organ failure. While the nursing team could have taken further steps to monitor Dr J’s skin, the priority was on providing Dr J with lifesaving multiple organ support to prevent further deterioration and cardiac arrest. This would have involved putting in vascular access, a central line, an arterial line and renal replacement line. It is likely the priority of the nursing staff would have been to support the doctors at this time, rather than monitoring Dr J’s skin. Our intensive care adviser considered Dr J’s management was in line with good clinical care and treatment, as supported by GMC Good Medical Practice, which says:
‘15 You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a) 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 b) promptly provide or arrange suitable advice, investigations or treatment where necessary…’
30. As noted in the WJES review, typical signs of necrotising fasciitis include severe and increasing pain out of proportion. Following Dr J’s admission to ICU, he was still not experiencing any pain according to what is documented in the records. For instance, at 5am it is documented his pain score was one out of 10. Our ICU adviser explained it is possible Dr J’s ability to feel pain was impacted by how unwell he was with liver and kidney failure, but it would still be expected a patient would feel some pain and agitation when being moved.
31. It became evident that the Trust needed to reconsider necrotising fasciitis when nursing staff noted concerns that the condition of Dr J’s skin was getting worse. This was at approximately 5am on 30 September. We acknowledge Prof. A says he drew attention to the fact his brother’s rash was spreading but note this is not reflected in the records. In any case, we cannot say nursing staff would not otherwise have identified the worsening of the rash. A multi-disciplinary team (MDT) meeting took place and was documented at approximately 8am. Our intensive care adviser said it would be expected to take around two to three hours for senior specialists to complete their review and make a decision out of hours. We consider the concerns were addressed promptly in line with GMC Good Medical Practice, which says:
‘15 You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a) … b) promptly provide or arrange suitable advice, investigations or treatment where necessary…’
32. Overall, we consider the Trust’s management of Dr J was appropriate and in line with guidance. We note necrotising fasciitis was considered a possibility, with this being included in the differential diagnosis. Initially, the clinical picture was not in keeping with necrotising fasciitis and the priority was to put in place life-saving multi-organ support. Trust staff did make a note of the rash and it was identified this was getting worse, so Dr J was referred for debridement surgery.
33. Our surgeon adviser said the operation notes indicate debridement was thorough and two consultant surgeons were present. They explained it is the nature of necrotising fasciitis that even after debridement to normal looking tissue, the necrosis can progress rapidly, which is what appeared to be the case here. A BJS article on ‘Assessment and management of necrotising fasciitis’ says ‘A re-look procedure at 24–48 hours to further clean and debride wounds is mandatory and should be repeated until the wound is deemed clean and stable.’ This supports that necrotising fasciitis can progress, despite proper surgical intervention. Overall, we have not seen any evidence that debridement was not completed adequately.
34. We note the post-operative instructions state ‘Surgical team will aim to relook in 48 hours’ and ‘Keep dressings as they are next 48 hours.’ Our surgeon adviser said after the first debridement, close supervision with regular observation of the wound and surrounding skin is essential, especially in the context of a patient who was not improving. However, there is no instruction from the surgeons to monitor Dr J’s wound and skin. We consider this was a failing and was not in line with GMC Good Medical Practice, which says:
‘44 You must contribute to the safe transfer of patients between healthcare providers…This means you must: a) share all relevant information with colleagues involved in your patients’ care within and outside the team, including when you hand over care as you go off duty, and when you delegate care or refer patients to other health or social care providers.’
35. While the surgeons should have provided instructions to closely and regularly monitor the wound and surrounding skin, we do not consider the failure to do so had any clinical impact. Dr J had returned to ICU from theatre at around 3pm and then returned to theatre at around 9pm. We will never know whether more specific instructions would have led the nursing team to raise concerns earlier.
36. We have considered the advice from our intensive care and surgeon advisers. Both confirm that even if Dr J’s rash had been monitored more closely or regularly, leading to an earlier decision to operate (and we will never know if this would have happened), it is unlikely this would have changed the outcome. Our surgeon adviser referred to a PubMed article in relation to a study which found the rate of fatality for patients with streptococcal toxic shock syndrome was 39%. Dr J’s chances of survival were even more limited given his multiple other health conditions and his multi-organ failure. In addition, Dr J’s symptoms had been ongoing for several days before he attended the ED, and when he arrived he already had overwhelming sepsis.
37. Our decision is to partly uphold this complaint. We appreciate Prof. A feels strongly that his brother did not get adequate care and treatment and that he has some relevant experience being a surgeon by profession. We appreciate how upsetting this must be for Prof. A and hope our explanations for our decision go some way to resolving his outstanding concerns.