Skin and feet 14. We recognise Ms L has significant concerns about the Trust’s management of her father’s skin, particularly around his foot and podiatry care. She explains he had diabetes, so it was very important he received timely care. Ms L says her father’s skin and feet were initially in good condition but by December he had black marks on his feet and she questions how this was missed.
15. The Trust says daily checks of Mr Y’s skin were complete, and referrals were made to the appropriate teams for specialist input at the correct times.
16. Our podiatry, tissue viability and nursing advisers have very carefully considered the management of Mr Y’s skin and feet to understand if anything went wrong. We understand this was a significant period of care spanning eight months and will go through this chronologically.
17. It is important to note each of our advisers have acknowledged the documentation is incomplete and inconsistent throughout the period. There does appear to be missing information, for example intentional rounding charts. Based on this, it is not always possible to know what was happening. Our advisers have used the medical photography to assist them.
18. From a careful consideration of the evidence that is available, we understand Mr Y’s skin and feet were initially in a good condition on admission, as Ms L has told us, and we will explain more about this below.
19. The pressure ulcer guidance covers risk assessment, prevention and treatment. It aims to reduce the number of pressure ulcers for patients receiving NHS care. It sets out the steps that should be taken including risk assessments, care planning and repositioning.
20. The records show an appropriate care plan was put in place for Mr Y regarding pressure ulcer prevention. It stated he needed regular skin inspections and pressure relief. The care plan initially suggested two hourly pressure relief, but that this may need to change on inspection.
21. Our nursing adviser explains initially there is reasonable evidence to show there were good pressure ulcer prevention strategies in place, and pressure relieving equipment used. Mr Y had regular reviews and interventions, with risk assessments documented on a regular basis and adherence to his care plan.
22. Mr Y did develop some initial pressure damage to his skin, with tissue damage to the sacral area in August 2023. Pressure damage cannot be entirely avoided whilst a patient is in hospital and is often deconditioned. He was appropriately referred to tissue viability, and a detailed plan was put in place, with advice for a daily dressing regime, and care plan explaining he should be turned two hourly, with advice not to use foam dressings.
23. He was followed up by the TVN team on 7 September and they advised nursing staff to use a slide sheet to help with repositioning, to help any further damage to Mr Y’s sacrum. This was an appropriate plan from the TVN team with clear instructions.
24. The TVN team also highlighted Mr Y’s feet were pressed up against the footboard of the bed. They advised to seek further advice from the podiatry if there were any issues with this. His other pressure areas were checked at this review, and his skin was noted to be intact, with no discolouration or skin breaks.
25. It was noted a foam dressing had been incorrectly used for the sacral wound. The TVN team replaced this with the correct dressing. At the TVN review on 2 October, a foam dressing was incorrectly in place again. The TVN team redressed this and reiterated its advice and instructions to the ward. His other skin all remained intact at this review.
26. At the TVN review on 9 October and 23 October, an incorrect foam dressing had been used again. The TVN team redressed this and gave further advice.
27. We are mindful of this and recognise this suggests the nursing team were not following TVN advice regarding Mr Y’s sacral wound. We acknowledge this is not ideal. We are reassured the TVN team promptly noticed this and were able to put the correct plan back in place to prevent further deterioration. The initial pressure damage therefore could be seen to be improving as a result of the TVN interventions.
28. Mr Y’s skin was reviewed again on 13 November. His sacrum had improved further, and the wound had healed. As a result, he was able to be discharged from the tissue viability service. The TVN team advised if his skin deteriorated, he needed to be rereferred back to them. Our TVN adviser explains this was an appropriate plan, and the overall management was in line with the above guidance.
29. Regarding Mr Y’s feet specifically, there also did not appear to have been any significant problems with his feet during this initial part of the admission. The diabetic foot guidance is relevant here.
30. This guidance sets out a diabetic patient’s feet should be checked on admission. There is no documentation within the records to show this took place. However, our podiatry adviser explains the evidence suggests there was initially a care plan in place for diabetics, alerting staff to check Mr Y’s feet. The care plan said Mr Y’s feet were to be checked at regular intervals. The records show at the start of the admission, Mr Y’s feet were in good condition and there do not appear to have been any issues or need for podiatry input.
31. For diabetic feet, there is no clear specification on how often a patient’s feet should be checked by the podiatry team specifically. As Mr Y was presenting as initially low risk for foot complications, the podiatry team would not check his feet directly unless they were alerted by the ward staff to a change in his condition. It was reasonable that checks were initially carried out by nursing staff.
32. On 6 October, we recognise the family expressed their concerns about Mr Y having diabetes, and the need to care for his feet, asking for a podiatry referral. The referral was made and the podiatry team reviewed Mr Y on 23 October. They advised he had sore nails and toes, with all nails overgrown. His nails were cut and filed, and it was documented he had no soft tissue infection present. A dressing was applied to the right toe following trimming. The team arranged for a follow up review in one weeks’ time.
33. The podiatry team reviewed Mr Y as planned a week later, on 30 October. His dressing was removed, and the tissue has settled and was intact. There was no soft tissue infection present. The podiatrist made a plan for the ward to redress this twice weekly, with podiatry follow up in a week.
34. On 6 November, the podiatry team reviewed Mr Y again as planned. The issues with his feet had resolved, the correct offloading was in place for his heels and there were no concerns about the blood flow to his feet. His feet had been thoroughly checked, and he had no wounds. The team advised the nursing team to re-refer and contact them if there were any problems or deterioration to Mr Y’s feet. As a result, it was appropriate to discharge Mr Y from podiatry, with safety netting in place. Our podiatry adviser explains this management was in line with the diabetic foot guidance.
35. Based on our TVN, podiatry and nursing advisers’ consideration of Mr Y’s skin and feet, we can see management was appropriate up to this point. It is reasonable to assume that his skin and feet were in good condition up until this point in mid-November. We are mindful there were problems with the dressings that had been used to the sacrum but can see this wound had healed and responded to treatment.
36. The appropriate plans were in place, and the TVN and podiatry team recommended two-hour pressure relief, highlighting Mr Y’s feet hitting the end of the bed. We are reassured the care up to this point was in line with the pressure relief and diabetic foot guidance.
37. We understand that then, on 29 December, Mr Y was documented to have a ‘necrotic grade three to his left foot’. On 30 December, the records say it is unclear how long it had been there. On 31 December, this is recorded as a ‘grade four and necrotic sore’. Necrotic refers to dead tissue. We acknowledge Ms L explains her father’s feet had black areas.
38. Pressure ulcers are categorised in stages. Category, or stage one is where the skin is intact but red and remains red if it is pressed. Category two is where there is partial skin loss and the skin is broken or blistered. Category three is where there is full thickness skin loss, and the damage goes deeper into the skin. Category four is where there is damage exposing muscle, bone or tendons.
39. From mid-November, as set out above, Mr Y had no skin damage and had been discharged from the TVN and podiatry teams. It was then the responsibility of the nursing team to carry out daily checks of his feet and skin. The care plan in place advised two hourly skin checks with the advice to re-refer to either team if there was a change in his skin or feet.
40. Each of our advisers have carefully considered the period that followed and cannot see from the evidence that two hourly, or daily checks were made of Mr Y’s skin or feet, in line with his care plan.
41. Intentional rounding documentation is missing throughout the period. Some entries are incomplete with gaps, particularly around December before the wounds were found. Intentional rounding is a nursing process to evidence staff regularly checking patients to address their needs, which we cannot see consistently took place. The Trust’s intentional rounding charts also do not alert staff specifically to check a patient’s feet.
42. The records also suggest the recommendations in place from the TVN team were not always followed, specifically around its instructions to stop Mr Y’s feet sliding down the bed. There is no evidence within the intentional rounding to show Mr Y’s heels were being offloaded. It is unclear if the bed board was being managed appropriately and the documentation around this is not consistent.
43. Risk assessments for this period are also inconsistent. Pressure ulcer prevention has a two-tier approach. To prevent pressure ulcers from initially occurring, a patient is placed on the ‘primary prevention pathway’ if they are at risk but have no damage. If a patient has an existing ulcer, they are placed on a ‘secondary prevention pathway’. This is a pathway for pressure ulcers to manage existing damage, promote healing and prevent recurrence. It is used for early detection and management to prevent deterioration.
44. If a patient is on a secondary prevention pathway, they are reviewed more frequently to track healing. Our advisers explain Mr Y should have been on secondary prevention pathway, but the documentation flips between him being on a primary and secondary pathway, inappropriately.
45. The records show different and conflicting terminology to refer to Mr Y’s wounds and show inaccuracies. For example, the type of mattress or equipment being used changes, and it is not clear what plan is being followed when, or what equipment was in place.
46. Within the records, different teams have described Mr Y’s wound’s differently, and there is not consistency between this in the documentation.
47. Each of our advisers have considered the wound photography and explain these wounds on Mr Y’s feet were quite advanced. Although we cannot say for certain exactly when his skin started to break down, these types of wounds do not happen overnight and go straight to becoming necrotic. On balance, it is likely these wounds had been missed for a period of weeks. This is supported as Mr Y had developed osteomyelitis, an infection in the bone, which can take a few weeks to develop.
48. We acknowledge Mr Y had diabetes, and this can impact skin damage. His diabetes appeared to be quite well controlled. Our advisers’ views are that these wounds to Mr Y’s feet appear to have been caused by his feet hitting against the bottom of the bed, and his heels by the unrelieved pressure.
49. At the beginning of the admission, the TVN had noted Mr Y was sliding down the bed, with his feet hitting the bed base. We acknowledge diabetes may have contributed to Mr Y’s skin integrity, but these appear to have been caused by pressure damage.
50. The nature of how these types of lesions and pressure ulcers progress supports that staff were not regularly checking Mr Ys feet. This is because when the pressure ulcer was eventually highlighted, it was a category four. A category four wound takes a significant amount of time to develop.
51. Taking into account the inconsistency in the medical records, advice not being followed to offload Mr Y’s heels and the gaps in intentional rounding documentation, we think Mr Y’s skin and feet were not checked in line with the pressure ulcer guidance, and something was missed. We think this is a failing.
52. We have also considered the management once the wounds on Mr Y’s feet were identified, from 29 December.
53. We acknowledge that from a podiatry perspective, he was then promptly referred back to them. The podiatry team then provided timely care, and reviewed Mr Y from 2 January and put an appropriate plan in place.
54. From a tissue viability perspective, we cannot see this management was in line with guidance. Our TVN adviser explains at this point, a referral should also have been made to the TVN team as instructed.
55. Our TVN adviser also explains if a patient has a category three or four pressure ulcer, which Mr Y did, this is seen as ‘harm’ and an investigation should be carried out with incident forms completed. This would consist of TVN coming to the ward, creating a plan, providing wound care and investigating how the harm happened. An investigation did not take place and incident forms were not completed. Mr Y was not referred back to TVN until 24 January.
56. To summarise, the management of Mr Y’s skin and feet was not in line with pressure ulcer guidance after he was discharged from TVN and podiatry in mid-November. We think his skin was not checked daily in line with his care plan. As a result, there was a missed opportunity to refer him back to TVN and podiatry for further care when his skin started to break down.
57. When his wounds were identified in December, we also think the management was not in line with the above guidance. He was correctly referred back to podiatry, but not TVN and the appropriate investigations did not take place. We think this is a failing.
58. We will carefully consider the impact of this below. Mr Y’s skin was not checked daily, and Mr Y’s wounds went unidentified and deteriorated. As a result, there was a missed opportunity for the specialist teams, TVN and podiatry, to be involved sooner to provide more specialist care and support. There was a missed opportunity to potentially prevent Mr Y’s wounds or stop them from deteriorating to this stage.
59. Our orthopaedic surgical adviser has considered if this could have been avoided, and the impact this had on Mr Y. It is acknowledged Mr Y went on to develop osteomyelitis, which is an infection in the bone.
60. Our orthopaedic surgical adviser explains Mr Y had extensive comorbidities and appears to have been on a gradual decline. He was experiencing lethargy, weight loss, chills, and decreased appetite. His past medical history included type two diabetes, hypertension, pan-gastroduodenitis (inflammation of the stomach), enlarged prostate, previous transurethral resection of the prostate, bilateral tiny lower pole renal calculi (small stones in the kidneys), mild thickening in the rectal wall suggesting inflammatory colitis and awaiting a neurology review for generalised rigidity.
61. This type of decline over several months leads to a decreased condition, and as a result a decreased resistance to infection. It is important to consider osteomyelitis in the context of these chronic longstanding issues.
62. This is not to detract from the lack of monitoring of Mr Y’s pressure areas, and we think this did directly contribute to his pressure ulcers. Our orthopaedic surgical adviser has carefully considered the photographs and explains they are dry and chronic, and likely had been present for a period of time. There is an element of necrosis.
63. The X-ray report completed on 18 January shows mild erosion on the tufts of the great toe on both sides, indicating likely acute or chronic osteomyelitis. The tufts are the end of the toes in the distal phalanx, which is the last bone at the end of the toe. This does not appear to be extensive, as there was not extensive bone involvement.
64. Our orthopaedic surgical adviser explains it would have been helpful to have completed an MRI scan and bone samples at this stage, to understand the extent of the osteomyelitis to help guide treatment. Mr Y was started on appropriate antibiotics, as reviewed and advised by microbiology, for osteomyelitis.
65. Without an MRI or bone samples, our orthopaedic surgical adviser cannot categorically confirm Mr Y had osteomyelitis. However, this is likely, given the ulcers and X-ray changes at the end of the tones, alongside a wound swab which isolated MSA. Given this, Mr Y should have been reviewed by an orthopaedic consultant, which did not appear to take place.
66. Our orthopaedic adviser has carefully considered if the likely presence of osteomyelitis contributed to Mr Y’s overall decline, chance of recovery and if it contributed to his death. It is possible this could have been avoided, as if the infections had been picked up with specialists involved sooner, this could have minimised the extent of the infection. They explain this is unlikely to have significantly contributed to his death or chances of survival, in the context of Mr Ys comorbidities, clinical condition and evidenced decline.
67. Whilst we do not think this would have changed the outcome, we recognise this was another source of infection for Mr Y to contend with, whilst he was already unwell and suffering from urological infections. It is also recognised this is likely to have caused him pain and suffering, having significant pressure damage which was untreated for several weeks.
68. We understand this will be distressing for the family and recognise the worry this has already caused them. We recognise it must have been shocking when they were alerted to the poor state of Mr Y’s feet when they had asked for his feet to be closely monitored.
69. We have not yet seen the Trust has taken steps to put this right, so we have asked it to take action as a result.
Urology care 70. We understand Ms L also has concerns about her father’s urological care, specifically about its decision to refuse to operate, and not being able to get control of his repeated infections. She says there was a lack of input from the team, and this contributed to his deterioration.
71. The Trust says Mr Y had a long-term catheter, which he needed due to having an enlarged prostate, which put him at risk of recurrent infections. In the Trust’s view, it was not clear whether the infections were related to the enlarged prostate or not, and the urologist felt it was not appropriate to operate on Mr Y whilst he was an inpatient.
72. We have carefully considered if the urology department provided the appropriate input, support and treatment based on Mr Y’s repeated infections. GMC guidance is applicable here. It 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’.
73. The urinary tract infection guidance is also applicable. It provides guidelines for the control and management of catheter associated bacteria and catheter associated infection.
74. On assessment in August 2023, Mr Y’s history of urinary retention considered, alongside his history of failed trial without catheter, and repeated urinary infections. It was acknowledged he had previously undergone a TURP. At a review on 15 August, it was determined he was too unwell to consider a further TURP, but that this would be reassessed in three months’ time.
75. Our urology adviser explains it was recognised and acknowledged Mr Y had repeated issues with infection, which comes from being able to empty the bladder. Bacteria is something that gets into every person’s bladder, and if it is not emptied well this can lead to infection.
76. Mr Y’s bladder appears to have not been emptying well, as he was going into retention when he did not have a catheter. Our urology adviser explains there are two possible causes of this. The first is that the bladder was obstructed by the large prostate. The second is that Mr Y’s bladder was not very strong.
77. Our urology adviser explains the male bladder is quite muscular and some male patients genetically or inherently do not have strong bladders, or the ability to fully empty their bladder. As a result, sometimes even when a TURP has been previously performed, the issues are not able to be resolved. Our urological adviser explains it is a possibility Mr Y had some inherent bladder weakness. Based on this, it is uncertain if performing a TURP would have resolved the issues he was experiencing with repeated infections.
78. Alongside this, it is unlikely there was an opportunity for the TURP to be carried out during the admission as Mr Y does not appear to have been fit enough for surgery. There are risks surrounding any surgical procedure, particularly in a patient such as Mr Y who was unwell in hospital with comorbidities. Mr Y regularly had infections, and operating whilst he was unwell would have placed him at further risk.
79. Surgery would have presented a risk of sepsis, as introducing anything potentially infective into the urinary tract could have caused an episode of sepsis. It also posed a risk of bleeding, and a risk from anaesthetic and of further complications, for example in the chest leading to pneumonia.
80. The clinical frailty scale (CFS) is a tool used to identify if a patient is frail. A CFS score of five or more, indicates frailty. On admission, Mr Y’s frailty score was five. Patients who are categorised as frail are less likely to recover well from an operation, they are three times more likely to have complications and potentially die within a year of surgery. When carefully considering the risks and benefits of surgery, this is considered alongside the fact a TURP may not have resolved the issues.
81. Overall, this supports the decision that it would have been appropriate to consider a TURP as an outpatient, when Mr Y was in better health and optimised. It is possible if it had gone ahead things could have gone wrong. Based on this, on balance our adviser explains it was an appropriate plan to try to optimise Mr Y before going ahead, in line with the GMC and urinary tract infection guidance.
82. Recognising we do not think Mr Y was fit for surgery during his admission, our urology adviser has carefully considered if the Trust did what it could to manage his infections and catheter care.
83. The NICE urinary tract infection guidance explains the longer a catheter is in place, the more likely bacteria will be found in the urine, and after one month nearly all people would have this.
84. A long-term catheter like Mr Y had, generally should last three months. In practice they do not last that long in some patients. This is because some patients block up and become infected over a shorter period, as a result they need more frequent catheter changes. Catheters can become colonised quite quickly with bacteria.
85. Mr Y was having difficulty with repeated infection, as is evidenced by the records, our urology adviser explains it would have been reasonable to change his catheters more frequently than the three months stipulated in guidance. For example, fortnightly, or as often as the clinican deemed necessary in the circumstances.
86. Our urology adviser has very carefully considered the timeline of catheter care and management throughout the entire admission, recognising good catheter management is key to help minimise the risk of infection.
87. The evidence shows Mr Y’s catheter was flushed regularly, in line with urology advice. He was trialled without a catheter but went into retention. Mr Y was appropriately given a very large range of different antibiotics to treat catheter associated UTI, guided by microbiology.
88. Advice was given to change Mr Y’s catheter every six to eight weeks at the start of the admission. The evidence shows Mr Y’ catheter was changed more frequently than this to avoid infection, generally around every two weeks to three weeks, throughout the whole admission. Our urology adviser explains this management and input was in line with the urinary tract infection guidance.
89. We are mindful that despite intervention, Mr Y presented with continual infections. We think the Trust took the right actions in trying to treat this, but we acknowledge how worrying this must have been for them at the time.