Application of glue and steri-strips
20. Miss A complains the Trust did not apply the glue and steri-strip to O’s wound correctly. She says the nurse was initially unsure how to manage the wound, and the doctor initially suggested suturing the wound. After a further discussion between the nurse and doctor, a decision was made to use steri-strips and glue. Miss A says the doctor advised the nurse how to apply these, and a healthcare assistant supervised.
21. The Trust explained that its decision use glue and steri-strips for O’s wound was correct. It said that if the edges of wound can successfully be aligned then this can eliminate the need for a more complex procedure like applying sutures.
22. The Code says nurses must respect the skills, expertise and contributions of their colleagues, referring matters to them when appropriate. The HCA code also contains a similar section.
23. The medical records note the laceration on O’s face as being ‘3cm, partial thickness laceration to the left cheek, clean…’. In terms of how the glue and steri-strips were applied, the records state ‘wound cleaned, steri-strips applied and glue … doctor has checked wound before discharge’. This entry appears brief, but we would not expect the medical records to include the specific steps taken.
24. The photographs Miss A provided us shows us the different stages of the wound on O’s face. It starts with how the wound looked prior to treatment from the Trust, how it looked straight after the treatment, to further pictures of it during the healing process.
25. Both our nursing and plastic surgeon adviser have reviewed these photographs as part of their advice. They both advised that glue and steri-strips can be used for facial lacerations. For these to be used correctly, the wound edges are to be aligned so as to not leave any space. It is also important for there to be no significant tension on the wound edges which could result in the wound reopening.
26. Information from the NICE CKS on laceration supports this, as does the manufacturer’s instructions for the products. This method (steri-strips and glue) can be effective for closing small, simple lacerations in low-tension areas when the edges of a wound are brought together leaving any space.
27. As such, we do not think there was a failing in the nurse initially attempting to close the wound in this way. It does not fall outside of the advice for when glue and steri-strips should be used.
28. Our plastic surgeon adviser, however, explains that due to the location and the type of wound O had on his face, it was unlikely the wound edges could be brought together and aligned. They explain this would have likely been apparent early on in attempting to close the wound that the nurse could not properly align the edges using this method.
29. Our nursing adviser says this is evidenced in the photographs Miss A took of O’s wound after the procedure. It shows the wound edges are not aligned, there is tension on the wound edges, and there is a gap between the edges.
30. At the point where it became clear the nurse could not align the wound edges, our plastic surgeon adviser says the nurse should have sought advice from a colleague. This could have included advice from a plastic surgeon, during the application of the glue and steri-strips, or after.
31. We have seen no failing in the decision to attempt to use steri-strips and glue. We have found the Trust’s actions once application was attempted are not in line the Code and the HCA code. It should have become clear edges of the wound could not be aligned, with no tension, and leaving no gap (whether during or after application). At this point, the nurse should have sought advice from a colleague, such as a plastic surgeon. This did not happen.
32. There are failings here. We will consider the impact of this later in the report.
After-care
33. Miss A complains the Trust did not provide her with any aftercare advice for O’s wound.
34. At the time of its response to Miss A’s complaint, the Trust said it did not have any leaflet-based aftercare instruction sheets available for patients regarding wound care. It explained that healthcare professionals typically ensure patients receive sufficient aftercare and ‘safety netting’ advice upon discharge. Healthcare professionals communicate this verbally and it is also included in its patient discharge letter.
35. The RCEM guidance says the treating clinician is responsible for providing the discharge advice, whether verbal, written, or online. The discharge advice should include, but is not limited to:
• condition specific advice • self-care advice and issues to specifically look out for, where appropriate • advice on what to do if things do not improve, for example, contact GP or NHS 111 • advice on what to do in the event of developing an associated emergency complication, for example, contact 999 or go to A&E • follow-up arrangements.
36. This guidance does not say the clinician has to provide written advice. It does recognise that providing written information is effective in improving patient recall of advice and instructions. It also explains that providing written information, in addition to verbal advice given by clinicians, can be helpful.
37. The medical records say the doctor provided Miss A with a head injury leaflet. Verbal and written advice are circled, as well as ‘safety net’. Next to ‘safety net’, the records reiterate that ‘head injury advice leaflet given’.
38. Both our nursing and plastic surgeon adviser says it is not possible to know what kind of verbal advice the doctor gave Miss A. This is because the records do not indicate the content of the verbal advice the doctor provided. We also do not have any statements from the individual staff members involved to also provide further evidence.
39. Miss A said the Trust did not tell her when and how the steri-strips should be removed. She said the Trust advised her that the strips would loosen on their own and fall off.
40. Our plastic surgeon adviser explains says there would have been a natural tendency for the steri-strips and glue to have separated spontaneously as wound healing progressed. The Trust should have outlined this to Miss A. Again, there is nothing in the records to indicate the Trust provided this advice to Miss A.
41. Considering the evidence, including what Miss A has told us, we think it is more likely than not that the Trust’s actions are not in line with the RCEM guidance. There is nothing in the Trust’s records to indicate it provided the appropriate after care and discharge advice to Miss A.
42. On the balance of probabilities, we have found it is likely the Trust did not provide Miss A with aftercare advice for O’s wound. There are failings here. We will consider the impact of this below.
Impact
43. We have found failings in the Trust’s application of the glue and steri-strips to O’s wound, as well as the lack of aftercare advice given to Miss A.
44. Miss A says O’s wound on his face has not healed properly and has left him with a red, raised scar. She says this has negatively affected her son’s confidence as other people always ask him what happened to his face. As such, he no longer like to socialise or go out with others.
45. As explained in paragraph 30, when it became clear that the nurse could not successfully align the wound edges with the glue and steri-strips, the nurse should have sought advice from a colleague. This could have been a colleague like an Emergency Medicine doctor, or plastic surgeon.
46. Our plastic surgeon adviser has explained they regularly provide advice regarding the management of wounds in real time, and that this is actively encouraged. They explained they would have recommended the use of sutures to close the wound if they had been asked for advice. We note the consultant at the different NHS Trust who provided their opinion in the Trust’s complaint response also said they would have likely opted to suture the wound.
47. The wound was jagged and extended through the skin into the tissue beneath, and the wound edges were gaping. Our plastic surgeon adviser explained this was to be expected considering how O had sustained the injury, as a fall into a hard surface would have resulted in a ‘burst’ laceration, or splitting open of the skin.
48. Our plastic surgeon adviser has explained O’s scar developed because the wound edges were not accurately lined up without leaving a gap. They explained because of this, the wound healed by secondary intention, where the gap fills with healing tissue and the new skin grows over the top. As such, this resulted in a longer wound healing time and a less aesthetically pleasing result.
49. Our plastic surgeon adviser explained suturing would have allowed for a more detailed inspection and cleaning of the wound. It would also likely achieve the optimal aesthetic outcome as the wound could have been debrided (removing dead tissue). The placement of sutures would have also allowed a more accurate alignment of the edges.
50. Our plastic surgeon adviser did highlight that due to O’s age, it is possible he would have needed to be transferred to a hospital which provided paediatric plastic surgery facilities. It would have been likely that he would have needed general anaesthetic in order for the sutures to be placed.
51. If it had been the case that Miss A and O had been unwilling to be transferred or to undergo general anaesthesia, or if he had any health issues which could have impacted this, then this would have been a reason to continue with the steri-strips and glue. We have seen no evidence that this was discussed, or that this was the case.
52. We understand knowing that the outcome of O’s scar could have been different will be upsetting and frustrating for both Miss A and O. We understand how the look of O’s scar has affected his confidence, and he is not as outgoing as he was before as a result. We recognise this will likely continue to have an impact on him for some time. We also acknowledge how upsetting it is for Miss A, as O’s mother, to know this could have been avoided.
53. Regarding the lack of aftercare advice, Miss A said this made her feel like the Trust did not take, or treat, O’s wound seriously. We understand that not receiving any aftercare advice from the Trust would have made Miss A feel like this.
54. In terms of aftercare advice, the Trust has said it has developed a wound care instruction leaflet. The leaflet was made available for any healthcare professional to access and to print a copy for patients and their families at any time. The Trust has reinforced the significance of providing this information to all clinician and that it has taken this has a lesson learnt from the complaint.
55. It is encouraging to see that the Trust have developed written information on wound care because of the complaint. However, we do not think this is enough to put things right for Miss A and O.
56. We have outlined our recommendations below.