University Hospitals of North Midlands NHS Trust
21. Miss R is unhappy about Mr R’s treatment for pressure sores when he was in hospital from 2 to 10 September 2020.
22. The management of pressure ulcers for adults is set out in NICE Guidance CG179. This guidance sets out the recommended assessments and treatment a patient should receive.
23. Mr R was risk assessed when he was admitted using a Waterlow risk assessment which is a validated tool for evaluating the risk of a patient developing pressure ulcers. NICE quality standard QS89 says that this assessment should take place within six hours of admission. Mr R had this assessment about an hour after being admitted to the ward.
24. The Waterlow score at this point was incorrectly calculated and should have led to Mr R being recorded as ‘high risk’ rather than ‘at risk’.
25. NICE guidance CG179 also explains that a skin assessment should take place, and a body map was appropriately completed on 3 September, where it was recorded that Mr R’s pressure areas were intact. A SSKIN (surface, skin, keep moving, incontinence, nutrition) bundle tool was used to assess Mr R’s risk of developing pressure damage and document his repositioning schedule.
26. The SSKIN assessment and repositioning of Mr R was initially completed every four hours, but this was increased to every three hours from 4 September. NICE guidance CG179 says that patients at high risk of developing pressure ulcers should have their position changed every four hours.
27. As part of the SSKIN assessments it was recorded that nurses tended to Mr R’s personal care needs, checked pressure areas, managed incontinence and repositioned as required. It was recorded that sometimes Mr R could be non-compliant, and our nursing adviser has explained this would have made washing and repositioning Mr R challenging at times.
28. As stated above, Mr R’s Waterlow score was incorrectly calculated. Despite this, Mr R was repositioned at a level suitable for a high-risk patient. The North Midlands Trust has acknowledged the error in the Waterlow score in its complaint response and taken action to address this with staff on the ward to prevent recurrence.
29. Our hospital nursing adviser has reviewed the relevant SSKIN documentation and explained that moisture lesions were recorded during the period of Mr R’s hospital admission, but there is no record of pressure damage. However, the discharge transfer form states that Mr R had a grade two pressure ulcer to his gluteal cleft. Our nursing adviser confirmed this was the only time this is referred to in the medical notes.
30. Mr R was assessed as being medically fit for discharge on 10 September. NICE guidance CG179 sets out the relevant management of pressure damage, but does not say that either moisture lesions or pressure ulcers should be treated in hospital, or that they are a reason not to discharge a patient. Mr R was being discharged back to a residential home with training in the management of skin issues and awareness of the guidance around monitoring and treatment. We are not persuaded Mr R’s pressure damage meant that he should not be discharged, and our hospital nursing adviser supports this view.
31. Based on the evidence we have seen we are satisfied Mr R received appropriate treatment for his pressure areas whilst he was in hospital. The treatment Mr R received was in line with the relevant NICE guidance.
32. Miss R is also unhappy with North Midlands Trust’s management of the safeguarding process. She believes the North Midlands Trust did not suitably act on safeguarding concerns raised by Mr R’s residential home, kept information from her and denied telephone calls about the outcome of the process took place.
33. Miss R has said that on 2 December 2020 a member of staff from the North Midlands Trust called the residential home and ‘admitted accountability’ for the pressure sore Mr R had when he returned to the residential home from hospital. Miss R has said that the residential home staff member told the North Midlands Trust that the family were too distressed to take a telephone call, and therefore the North Midlands Trust agreed to write to Miss R ‘admitting accountability’. Miss R says this letter was never sent. The North Midlands Trust has said in its response that it has no record of the telephone call.
34. Miss R also says she spoke with a member of North Midlands Trust staff about the safeguarding concerns, who initially offered to send Miss R a copy of the investigation document, but this offer was later rescinded.
35. From the information we have seen, it seems the issue of Mr R being discharged to the residential home with a pressure ulcer was reported to the North Midlands Trust. The Trust investigated and concluded that the issue was a discharge concern, rather than a safeguarding issue, and that Mr R’s skin damage whilst an inpatient was recorded only as moisture damage, rather than a pressure sore.
36. As explained above our hospital nursing adviser has commented that the only reference to a pressure ulcer was on the discharge form, with moisture lesions reported during his admission. The North Midlands Trust investigation of the issue is accurately reflected by the records, however, there has clearly been a breakdown in communication with Miss R.
37. We can see no record of a telephone conversation where the North Midlands Trust has ‘admitted accountability’. We appreciate this is an area of upset and frustration for Miss R, but we cannot add anything further about this issue.
38. When Miss R spoke to the North Midlands Trust about its investigation of the issue, it seems she was offered a copy of documentation, but this decision was later changed. This poor communication would have added to Miss R’s frustration at what was already a difficult time. We would not expect the North Midlands Trust to share internal documents about its investigation, but this should have been made clearer to Miss R.
39. The North Midlands Trust has explained in its written complaint response the actions it took to investigate the issue. The North Midlands Trust has suitably explained that moisture damage was recorded whilst Mr R was in hospital and it is unclear why this was different on the discharge form, as this is not supported by the records.
40. The most relevant guidance we can consider here, is PHSO Principles of good administration:
Public bodies should communicate effectively, using clear language that people can understand and that is appropriate to them and their circumstances.
41. We are not persuaded that during the process the North Midlands Trust communicated effectively, but the later written response accurately reflects the records and explained the investigation it had completed.
42. Whilst there is evidence of poor communication, this does not fall so far below the relevant standard to indicate failings.
Midlands Partnership NHS Foundation Trust
43. Miss R is unhappy with Mr R’s treatment for pressure sores from the district nurses when he was in the residential home from 10 to 26 September 2020. The district nurses were employed by the Midlands Partnership Trust.
44. The residential home staff called the district nurses on 11 September asking them to look at Mr R’s pressure areas and they attended the following day.
45. The relevant guidance for this initial assessment is NICE CG179. This guidance sets out the recommended assessments and treatment a patient should receive. This includes the requirement for an initial assessment, pressure ulcer risk assessment, consideration of comorbidities, developing a care plan, equipment requirements and discussing the plan with relevant carers.
46. An initial wound assessment took place on 12 September, and it was recorded that Mr R had an uncategorised pressure ulcer, measuring 10mm by 3mm. A general skin assessment and check of all pressure areas recorded the surrounding skin as being healthy and intact. The Walsall pressure ulcer risk tool (an assessment tool commonly used in community nursing settings) was completed. The area was cleaned and dressed.
47. With regard to Mr R’s care planning it was documented that written and verbal advice was given to the care team about position change, nutrition, equipment requirements and that the GP was to be contacted regarding pain relief.
48. NICE CG179 explains how a care plan should be developed taking into account the relevant information from the assessment. From the evidence we have seen the actions by the district nurses at the initial assessment on 12 September were appropriate and in line with the relevant guidance. Mr R was suitably assessed, a suitable care plan was in place and relevant discussions took place with the residential home carers.
49. Mr R was next seen by the district nurses on 15 September. A brief assessment of Mr R’s wound was recorded, and the home staff were advised to apply medi-derma cream. Mr R’s wound had already been assessed on 12 September which was in line with the relevant NICE guidance. Although the further assessment of Mr R’s wound was brief, there is no specific requirement in the guidance that a full wound assessment should be completed at every visit. Therefore, we have not seen any evidence of failings in this brief assessment of Mr R’s wound.
50. Whilst we are satisfied the assessment of Mr R’s wound was in line with the relevant guidance, NICE CG179 also sets out the how a patients overall pressure risks should continue to be monitored.
51. NICE CG179 says that pressure area risk should be reassessed if there is a change in clinical status, using the example of the worsening of an underlying condition or a change in mobility. Our community nursing adviser has commented that Mr R’s records indicate that his mobility was deteriorating. Taking into account this ongoing change in condition and deterioration we consider a further pressure area assessment should have taken place.
52. The district nurses next assessed Mr R on 18 September and it was recorded that the wound was ‘nearly healed’. Details about the extent of Mr R’s wound were appropriately recorded by the district nurses with relevant measurements. As we have explained above there should have been a further pressure risk assessment completed as Mr R’s mobility was an ongoing concern.
53. The lack of updated pressure area risk assessments on 15 and 18 September was not in line with the relevant NICE CG179 guidance and indicates failings in the actions of the Midlands Partnership Trust.
54. On 18 September the decision was made to discharge Mr R from the care of the district nurses. The relevant guidance here is the NMC code. This guidance says:
Be accountable for your decisions to delegate tasks and duties to other people
To achieve this, you must:
- only delegate tasks and duties that are within the other person’s scope of competence, making sure that they fully understand your instructions - make sure that everyone you delegate tasks to is adequately supervised and supported so they can provide safe and compassionate care - confirm that the outcome of any task you have delegated to someone else meets the required standard
55. We have not seen any evidence to suggest that pressure area management was within the home staff scope of competence, that home staff were adequately supervised and supported or that the district nurses arranged a follow up to ensure pressure area management met the required standard. The actions of the Midland Partnership Trust were not in line with the NMC guidance.
56. Mr R’s records indicate that he deteriorated over the weekend of 19/20 September and continued to do so over the following week. The district nurses completed a wound assessment on 25 September which documented a deep tissue injury (DTI). An appropriate wound assessment took place including measuring and categorising the wound and applying relevant dressings. An updated assessment of Mr R’s pressure area risks took place, and there was a discussion with Mr R’s family to explain that the wound was as a result of Mr R’s comorbidities and reduced nutrition.
57. The wound assessments and treatment here were in line with NICE CG179 guidance. Our community nursing adviser has explained Mr R was sadly at the end of his life and that the focus of his care at this time was to try and promote his comfort, rather than heal the ulcer.
58. Miss R also says that staff did not treat Mr R’s pressure sores for a period of around ten days because of concerns about Covid-19.
59. We have not seen any evidence that Covid-19 was a factor in the decisions by district nurses to treat Mr R’s pressure sores. We have explained above the failings we have identified in this regard.
Impact of the failings
60. We are sorry to hear about the traumatic time Miss R and her family suffered. We have seen evidence of failings in the ongoing assessment of Mr R’s risk of pressure ulcers and his discharge from the care of the district nurses.
61. As we have explained we are not persuaded that the home staff had the relevant competence to manage Mr R’s pressure areas. It was recorded on 23 September that the skin on Mr R’s sacrum was intact. This could be reassuring; however, our community nursing adviser has explained that a DTI can present as a purple or maroon area of intact skin.
62. Further input from the district nurses, rather than discharge, could have prevented the progression of the wound to a DTI, because district nurses would have had the relevant knowledge to notice the deterioration and treat the wound before it reached the DTI stage. However, this is not certain as we cannot predict how the wound may have presented.
63. Our community nursing adviser explained that end of life wounds can still be treatable, or they can be maintained and therefore not progress, or even with the best of care, DTIs can still develop.
64. The SCALE expert panel says:
Even with the stress of dying, some lesions are healable after appropriate treatment.
Preservation refers to situations where the opportunity for wound healing or improvement is limited, so maintenance of the wound in its present clinical state is the desired outcome.
A palliative or non-healable wound may deteriorate due to a general decline in the health of the patient as part of the dying process.
65. It is very difficult to anticipate what might have happened to Mr R’s pressure sore if different treatment had been provided. Mr R’s deterioration was at a time when his pressure ulcer had almost healed with his deterioration taking place over the weekend of 19/20 September. It is possible the DTI would not have developed if Mr R had been assessed differently or had not been discharged, but it is also possible it would have developed anyway.
66. In considering what impact the potential failings we have identified would have had, we therefore need to take a balance of probabilities view, where we consider what is more likely than not to have happened.
67. This is very difficult in these circumstances as there are many variables to consider. From the evidence we have seen, on the balance of probabilities, we are not persuaded that Mr R’s deterioration and death can be attributed to the failings we have identified. Our community nursing adviser shares this view.
68. Whilst we are not persuaded the failings impacted on Mr R’s death, it is possible different treatment could have meant the DTI did not develop or was not as severe. Miss R has explained that the DTI caused Mr R considerable pain, and the events were extremely difficult and upsetting for Mr R’s family. We are unable to say if different treatment would have meant the DTI would not have developed, even on the balance of probabilities, as there are too many variables. However, the lack of risk assessment and the discharge decision leaves Miss R in the position of never knowing whether different treatment could have made Mr R more comfortable at the end of his life.
69. As a result of the failings we have identified we are making recommendations to the Midlands Partnership Trust set out towards the end of this report.
The GP Practice
70. Miss R believes Mr R was not given adequate pain relief by the Practice GPs when he was in the residential home.
71. The relevant guidance for GPs providing patients with pain relief is GMC Good Medical Practice. This guidance says:
In providing clinical care you must:
-prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs -provide effective treatments based on the best available evidence -take all possible steps to alleviate pain and distress whether or not a cure may be possible
72. The GP from the GP Practice spoke with the carers at the home on 11 September. The carers were unsure if Mr R needed a review and the GP explained that he had seen a doctor the day before, as this was when he discharged from hospital. The GP explained that the home could contact them if Mr R deteriorated. There was no record of any pain issues during this telephone call. Mr R had been discharged with pain relief that home staff could give him up to four times a day as required.
73. On 15 September the GP spoke with Mr R’s daughter as she was concerned that his pain was not being managed. As a result of this call the GP arranged to see Mr R the following day.
74. The GP therefore assessed Mr R on 16 September and recorded that he was comfortable and denied any symptoms. The GP also spoke with the home staff who did not feel he was in any pain.
75. Home staff spoke with the GP on 21 September, and it was recorded that Mr R had deteriorated over the weekend and that he was lethargic and struggling to swallow medication. The following day home staff spoke to the GP and reported that Mr R was in pain, despite his ongoing daily pain relief up to four times a day. Home staff asked the GP if the dose could be doubled, and the GP confirmed that it could be.
76. On 23 September home staff spoke with the GP and said that Mr R was in a great deal of pain despite his pain relief, including a morphine injection. The GP advised home staff to contact the district nurses to give him a higher dose of pain relief by further injection. The GP said that Mr R may need a syringe driver, and the GP would see how Mr R responded to the increased dose of injected pain relief first.
77. A syringe driver was started early on 24 September and further prescriptions for syringe driver morphine were made on 24 and 25 September.
78. It must have been a very upsetting and distressing time for Mr R and his family. Based on the evidence we have seen the GP Practice acted in line with the relevant guidance in providing pain relief to Mr R. He was suitably assessed, and the GP was aware of Mr R’s hospital admission and dementia diagnosis. Suitable pain relief was provided to Mr R, but we acknowledge that Mr R was in pain at times. Mr R’s ongoing pain relief was reviewed and increased as required and it was appropriate for the GP to see how Mr R responded to the increased does of injected morphine before the syringe driver was started. Our GP adviser has explained this is used as a guide to the amount of morphine used in the syringe driver.
79. We are satisfied that suitable steps were taken to try and alleviate Mr R’s pain. We are sorry to hear about these events. We can understand Mr R was in pain and we can also understand why Miss R has questions about the medication the Practice prescribed.