17. 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. If there are indications something did go wrong we look at whether this had an impact that has not been put right.
Podiatrist visit on the ward
18. The Trust explained the podiatrist went to visit Mr F on 20 December 2023 to provide advice on wound dressing, as per the referral they received at the time. The Trust said the podiatrist reviewed the photographs of Mr F's foot wound and discussed it with the nurse caring for him.
19. The podiatrist said she had been informed the specialist vascular team had reviewed Mr F’s foot pulses and graft that morning. The dressings used met the podiatrist's recommendations so they did not need to provide any further input on this.
20. They said it was not 'clinically indicated' to examine Mr F's foot and reviewing the graft and chest pain was outside of their specialism. The team had no concerns and Mr F was ready for discharge.
21. Our adviser explained there are no specific guidelines on whether the podiatrist should have examined Mr F’s foot. They said it is a matter of clinical judgement. The podiatrist in question was a member of HCPC at the time. We have therefore referred to HCPC guidance to understand how the podiatrist should have acted.
22. This guidance says the podiatrist should use their judgement to ‘make informed and reasonable decisions and meet the standards.’ They must take all reasonable steps to reduce the risk of harm to service users. They must also work in partnership with colleagues for the benefit of service users.
23. On 20 December the vascular team found Mr F’s foot was ‘warm and perfused’, which indicated blood was flowing well. He could feel his foot, there was no evidence of an infection and his dressings were clean and dry. This suggested he was recovering from the surgery as planned and the vascular team had no concerns about how Mr F’s foot was healing.
24. Our adviser explained this meant there was no need for the podiatrist to disturb Mr F’s wound dressings given the vascular team’s review. They explained it was not necessary for the podiatrist to review Mr F’s foot and there was no reason to keep him in hospital from the perspective of the podiatry team.
25. We therefore consider the podiatrist made a reasonable decision not to inspect Mr F’s foot. There was no need for the podiatrist to see Mr F in person given the information available to them. As there was no reason for Mr F to remain in hospital from a podiatry point of view, and they do not have the expertise to deal with someone’s chest pain.
26. We consider the podiatrist made an informed and reasonable decision when they decided not to review Mr F’s wound. They worked in partnership with their vascular and nursing colleagues and took the reasonable steps necessary to reduce the risk to Mr F. We therefore consider the podiatrist acted in line with relevant guidance.
27. This does not diminish the incredible upset Miss N has experienced or how much this complaint means to her.
Referral for community care
28. Miss N complains the podiatrist’s referral for community care was not done soon enough, did not contain enough information and was not marked as urgent.
29. The Trust said Mr F’s discharge summary requested a review with the high-risk foot team between six and eight weeks after discharge. It explained the referral was rightly not marked as urgent, and the review happened approximately two weeks after discharge which was sooner than recommended.
30. NICE guidance sets the standard for dealing with the foot problems Mr F had. Specifically, it says, ‘When deciding the frequency of follow-up as part of the treatment plan, take into account the overall health of the person with diabetes, how healing has progressed, and any deterioration.’
31. Patients with diabetes are at higher risk of developing problems with their feet. Our adviser explained the health of a diabetes patient can deteriorate quickly. This means prompt podiatry input is important to patient’s care. Our adviser said the ward nurse who arranged district nursing care for Mr F likely did not consider earlier podiatry input.
32. Additionally, with Mr F’s medical history and the community care in place at the time, it seems the district nursing team should have considered making an earlier referral to podiatry. However, there is no record in their notes they thought about this.
33. With the above in mind, it seems the ward nurse did not consider an urgent referral to the podiatry team. They should have done in line with NICE guidance. Consequently, it appears the referral did not contain enough information as Miss N claims and is an indication the Trust got something wrong.
34. We have therefore considered whether this could have resulted in the impact Miss N claims.
35. Miss N feels if district nurses or the outpatient podiatry team saw her father earlier then they might have identified his deterioration sooner and he would have received the treatment he needed to survive.
36. If the referral had been made for earlier podiatry input, then the specialist team could have seen him almost one-week earlier - approximately 1 January 2024.
37. However, community nurses saw Mr F several times after his discharge for dressing changes. They saw him on 24 December 2023, 29 December 2023, 5 January 2024 and 6 January 2024.
38. Mr F reported some pain at the appointments. Nonetheless, his wound was healing well, the nurses cleaned it successfully and changed his dressings. There was also no indication of an infection or that he felt acutely unwell. This would likely have been the same had the podiatry team seen him on or around 1 January.
39. Mr F saw the podiatry team on 8 January. His daughter and his former partner raised concerns about Mr F’s general unwellness, shortness of breath and shivering. The podiatry team could not hear pulses in his left foot where the operation was done. They advised him to go to hospital where he sadly died later that day.
40. Mr F was originally in hospital against the backdrop of foot disease due to his diabetes. His diabetes put him at risk of sudden deterioration, and we also know sepsis is an illness that causes sudden deterioration too.
41. Our adviser explained Mr F had already likely developed sepsis by 8 January and his condition had deteriorated since the last appointment two days earlier.
42. Sepsis was the reason for Mr F’s hospital admission on 8 January and the cause of his death the following day. It is unlikely Mr F would have had sepsis at an earlier podiatry appointment, and therefore the outpatient team could not have prevented it from happening.
43. Our adviser explained a referral for earlier podiatry input in the community would not? have made a significant difference to what happened to Mr F.
44. Therefore we cannot link any possible failings with the referral and the impact Miss N has claimed.
45. We understand this has been an exceptional source of heartbreak for Miss N. We hope our findings can bring some closure to her in time.