Trust A – Pressure sores
25. Mr H complains Trust A allowed a grade four pressure sore to develop during Mr I’s admission.
26. Overall, Trust A noted there were some gaps in the medical records which meant it was unable to confirm if pressure care was in line with its accepted standards or not, at certain times. However, it noted the records indicate Mr I had skin damage to his sacral (base of the spine) area as far back as June 2021.
27. NICE CG179 help us understand what should happen. This says adults assessed at high risk of developing a pressure sore should have a pressure sore skin assessment, and encouragement or support from staff to change their position at least every four hours.
28. It says staff should categorise each pressure sore in adults using a validated classification tool, such as the international NPUAP-EPUAP Pressure Ulcer Classification System. This system categorises pressure injuries into four stages.
29. The first is a category one pressure sore. This is intact skin that is a red, unblanching (does not fade when pressure is applied) area over a bony prominence (where bone is close to the skin).
30. Category two is partial thickness loss of skin presenting as a shallow open ulcer with a red, pink wound bed, without slough (dead tissue). Category three is full thickness tissue loss, under skin fat may be visible, but bone, tendon or muscle are not exposed.
31. Category four is full thickness tissue loss with exposed bone, tendon or muscle. Dead tissue may be present on some parts of the wound bed.
32. There are also categories where the depth is unknown, as the base of the ulcer is covered by dead tissue or slough. These can be classified as either unstageable or a suspected deep tissue injury.
33. NICE QS89 states people at high risk of developing pressure sores should have pressure redistribution devices. These work by reducing or redistributing pressure, friction or shear forces. These can include highspecification mattresses, pressure redistribution cushions and equipment that offloads heel pressure.
34. Using pressure redistribution devices as soon as possible can prevent pressure sores developing and help to treat them if they do happen.
35. We reviewed Mr I’s medical records for his admissions to Trust A between December 2021 and July 2022, with the help of our nursing adviser. We have set out each admission in separate sections below.
• 3 December to 27 December 2021 admission
36. The wellbeing rounds in the records show staff regularly helped reposition Mr I, usually at hourly intervals. These were less frequent throughout the night, when Mr I was sleeping.
37. The records also contain repositioning charts which again show regular position changes and skin checks. This is in line with NICE CG179 referred to above.
38. The records also show Trust A conducted a skin check on Mr I on the day of his discharge (27 December). This indicated Mr I had an old sore to his left buttock which was healed. This assessment also noted Mr I’s skin was pink and blanching in between the buttocks.
39. Similarly, on 28 December, the records from Trust B show staff assessed Mr I’s pressure sore risk. This noted Mr I had a category one pressure sore to his sacrum and moisture related skin damage.
40. Taking the above into account, the evidence available does not show Mr I developed a category four pressure sore during this admission at Trust A.
• 3 February to 16 March 2022 admission
41. On Mr I’s admission to Trust A (3 February) the records show he had the following pressure sores; category three left buttock, category three natal cleft (groove in between the buttocks), and category one buttock.
42. On 5 February, Trust A conducted and documented a full skin inspection. This noted he had category three pressure sores. The records on this day also show Mr I was on an air mattress. This is in line with the NICE QS89 guidance we have referred to above.
43. Throughout this admission the repositioning charts regularly refer to changing Mr I’s position every four hours, in line with the NICE CG179 guidance above.
44. On 1 March, the records indicate Mr I’s category three pressure sore was healing. On 5 March, the records indicate the pressure sore was still healing and that Mr I had a split natal cleft.
45. On 13 March, the records document Mr I had healed category three pressure sores to both buttocks and moisture lesion to the natal cleft.
46. On 16 March, the day of Mr I’s discharge, the last entry within the repositioning charts show Mr I had a healed category three pressure sore.
47. Therefore, the records show Mr I had a category three pressure sore on admission to Trust A, which was healing at the time of his discharge.
48. For this reason, the evidence does not show Trust A allowed Mr I to develop a category four pressure sore during this admission.
• 29 June to 5 July 2022 admission
49. The records show on Mr I’s admission Trust A used a pressure relieving mattress, maintained four hourly position changes and completed a full skin inspection. This is in line with the NICE CG179 and QS89 guidance referred to above.
50. The skin assessments indicate Mr I had a category four pressure sore on his admission to Trust A. This therefore shows Mr I already had a category four pressure sore before his admission to Trust A on 29 June.
51. For this reason, we do not consider the evidence shows Trust A allowed Mr I to develop a category four pressure sore during this admission.
52. Whilst we recognise the Trust said there are gaps in the documentation, based on the information above, the evidence does not show Trust A allowed Mr I to develop a category four pressure sore during these admissions.
53. We can see Trust A conducted frequent skin assessments, provided pressure relieving mattresses and helped Mr I change position regularly. This is in line with NICE CG179 and QS89. For this reason, we have not found a failing here and will not consider it further.
54. We recognise Mr H was understandably concerned about his father’s pressure areas and how Trust A cared for these. We hope our findings on his concerns provide reassurances Trust A provided pressure area care in line with the relevant standards and the evidence does not show it allowed Mr I to develop a category four pressure sore.
Trust B – Cather care
55. Mr H complains Trust B did not provide appropriate catheter care to Mr I during his admission from 27 December 2021 to 1 February 2022. A urinary catheter is a flexible tube used to empty the bladder and collect urine in a drainage bag. Mr H told us Trust B did not check the catheter bag or empty it frequently enough, causing urine to ‘back up’.
56. Trust B acknowledged it did not have enough staff on the ward where Mr I was staying, meaning that staff had to balance priorities of delivering care. It said on this occasion this was at the detriment of basic care.
57. RCN guidance on catheter care helps us understand what should happen. This says normal functioning kidneys produce a minimum of 30mls of urine an hour.
58. NMC guidance says nurses must make sure people’s physical, social and psychological needs are assessed and responded to. It also says nurses must accurately identify, observe and assess signs of normal worsening physical and mental health in the person receiving care.
59. For Mr I’s care, we understand this would mean nurses should have checked his catheter and draining bags regularly. They should also have acted on any signs of problems with the catheter.
60. We reviewed Mr I’s medical records from Trust B for his admission, with the help of our nursing adviser.
61. Our nursing adviser explained daytime catheter draining bags differ in sizes, ranging from 350ml to 750ml. Nighttime draining bags are typically two litres.
62. The records show frequent occurrences when staff did not empty Mr I’s catheter bag in a timely manner, mostly overnight.
63. For example, the records do not show staff emptied Mr I’s catheter overnight between 6 and 7 January 2022. Therefore, by the time staff emptied Mr I’s catheter on 7 January, there was 1200mls of urine drained.
64. Similarly, the records do not show staff emptied Mr I’s catheter overnight between 23 and 24 January. By the time staff emptied this on 24 January, there was 1100mls of urine drained.
65. This is not in line with the NMC guidance we have referred to above.
66. From the nursing advice we also understand, the records show issues with Mr I’s catheter and urinary output that staff did not escalate.
67. For example, on 10 January the records indicate Mr I’s catheter only drained 60ml between 11am and 11.59pm. On 22 and 23 January, the records show Mr I’s catheter was bypassing (urine leaking around the outside of the catheter instead of flowing through the tube).
68. The records also show between 7pm on 25 January and 6am on 26 January, Mr I’s catheter drained only 10ml. Following this, there are no fluid balance charts within the records before Mr I’s discharge on 1 February.
69. This is not in line with the NMC guidance we have referred to above.
70. Considering the above, we have found failings in Trust B’s management of Mr I’s catheter. We have considered the impact of this later in this report.
Trust B - Rehabilitation/mobility assistance
71. Mr H complains Trust B did not provide rehabilitation or mobility assistance to Mr I during his admission. Mr H said his father required this as he had Parkinson’s disease.
72. Parkinson’s disease is a condition that affects the brain and causes tremor, slow movement and stiff muscles.
73. Trust B’s response to this concern set out what rehabilitation and mobility assistance it provided to Mr I as noted within the medical records.
74. We discussed the care with our physiotherapy adviser and understand the most relevant guidance is the HCPC standards. These say physiotherapists must be able to practise autonomously, exercise their own professional judgement, assess and determine the nature and severity of a problem and call upon the knowledge required to deal with the problem.
75. These standards also say physiotherapists must be able to make reasoned decisions to initiate, continue, modify or cease techniques and record these decisions and rationale. They must also initiate resolution of problems, justify their decisions and make appropriate referrals.
76. We reviewed Mr I’s medical records with the help of our physiotherapy adviser to help us understand what happened.
77. The records show Mr I was admitted to Trust B on 27 December 2021. Trust B’s therapy team received Mr I’s referral on 30 December. This means there were 23 working days, from the therapy referral until Trust B discharged him, where Trust B could have provided Mr I with rehabilitation.
78. Trust B’s records indicate the therapy team visited Mr I on 18 out of the 23 days. On some of these days, the team visited Mr I twice. On two occasions Mr I refused rehabilitation due to back pain and a fall.
79. The records show Trust B provided a variety of interventions to improve and support Mr I’s functional status. These included transfers practice, bed and chair exercises, mobility practice and rehabilitation within the therapy gym.
80. From 13 January, the records show Mr I complained of back pain to the therapy team during the exercises. The therapy team liaised with nursing staff and doctors on multiple occasions to try and manage Mr I’s back pain.
81. For example, on 17 January, Mr I reported the exercises worsened his back pain. The therapy team agreed to visit Mr I after he had some pain relief. They also discussed optimising Mr I’s pain relief with the doctor to try to manage the back pain.
82. The therapy team also adapted Mr I’s therapy sessions due to his back pain. For example, on 18 January, Mr I reported back pain, so he agreed to exercises whilst sitting.
83. The records also show Mr I’s functional status improved during his admission to Trust B.
84. On his admission the notes show Mr I was mobilising and transferring using a sit to stand lift and assistance of two people. On his discharge the notes show Mr I was mobilising with a three wheeled walker and assistance of one person.
85. Based on the above, we can see Trust B worked regularly with Mr I to provide rehabilitation and mobility assistance, provided resolutions and referred him to other clinicians when he reported back pain. This is in line with the HCPC guidance above.
86. For this reason, we have not found a failing here. We hope this provides Mr H with reassurances Trust B provided rehabilitation to his father, in line with the relevant guidelines.
Impact
87. We found Trust B failed to provide appropriate catheter care to Mr I between 27 December 2021 to 1 February 2022. We have carefully considered the impact of this and discussed this with our geriatrician adviser.
88. Mr H told us the lack of catheter care caused Mr I to develop a urine infection, which led to a discitis infection requiring eight weeks of intravenous (through a vein) antibiotics. Mr H believes these infections contributed to the avoidable death of Mr I.
89. We are very sorry to learn about the upset and distress these events caused Mr H. It is clear from our communication with him that this was a very difficult time for him.
90. The records indicate, on 26 January, Trust B suspected Mr I had a urinary tract infection (UTI) and provided antibiotics.
91. The records show, on 2 February, Trust A suspected Mr I had discitis following an MRI scan.
92. Our geriatrician adviser explained it is difficult to link poor catheter care to a catheter associated urinary tract infection (CAUTI), for several reasons.
93. One reason is that good catheter care can reduce the risk of CAUTIs, but how much it reduces this risk is debatable.
94. There is evidence to show meticulous catheter care in the intensive care unit (ICU) environment, where there is one nurse per patient, can significantly reduce CAUTIs. However, there is much less evidence to translate this to the non-ICU environment, like a medical ward where Mr I was staying.
95. Adding to this, reducing the risk of CAUTIs is not only dependent on maintaining good catheter care but is also dependent on other factors.
96. These other factors include good fluid intake and other conditions such as diabetes (which Mr I had) which predispose people to UTIs. Elderly people also have lower immunity and ability to prevent or fight infection.
97. Further to this, finding a link between a urinary tract infection and discitis is also difficult. This is because discitis may be caused by direct spread from an infected neighbouring bone or spread through the blood stream.
98. When spread through the blood, it may come from any source of infection. For example, a UTI or pneumonia.
99. National Library of Medicine ‘Bacterial Spine Infections in Adults: Evaluation and Management’ sets out in many cases the site of infection is not found. In one research study, the source was not found in 42% of cases.
100. Our geriatrician adviser explained to link the urinary tract infection and discitis, the records would need to demonstrate the same bacteria grew in the urine and spine. Mr I’s records do not evidence this was the case.
101. Additionally, the records show Mr I was elderly and frail with a background of medical conditions including diabetes, Parkinson’s disease, heart failure, falls, recent COVID-19, bowel incontinence and obesity. Our geriatrician adviser explained Mr I was therefore at high risk of becoming unwell and deteriorating.
102. Considering the above, we recognise that, even if the Trust provided the most robust catheter care, Mr I would likely still have experienced a CAUTI and discitis. This is because, as set out above, these conditions are not solely a cause of poor catheter care and are dependent on a variety of factors.
103. Taking this into account, we have not found, on the balance of probabilities, the failings in catheter care caused Mr I to develop CAUTI, discitis and his death. This means we cannot link the failings to the injustice Mr H claims.
104. However, if the failings had not happened, we consider this would have made a difference to Mr H, as it would have given him reassurances Trust B were managing his father’s catheter in line with the relevant guidelines. Therefore, we have found the failings in Trust B’s catheter care caused Mr H avoidable distress.
105. We set out our recommendations below.