12. 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. We have carefully considered this in Mrs Q complaint.
Improper closure of the wound
13. Mrs Q is concerned the Trust failed to properly close B’s wound following surgery because it continued to bleed when he came out of recovery. We recognise this caused B significant distress at the time.
14. The Trust explained the wound was fixed internally with sutures and the outer wound then had skin glue applied. B’s surgical records show the wound was checked in recovery and documented as clean and dry. The Trust also said for this type of surgical wound, it is not normal practice to use a dressing over the top as the dressing can stick to the skin glue and prevent the skin from binding together.
15. In B’s case, it was evident he had become distressed when the theatre team started the transfer process. Sadly, during this time, the glue on the wound had not fully set yet and the outer edges of the wound began to open causing B pain and bleeding.
16. NICE guidelines explain how clinicians should treat and prevent surgical site infections. It focuses on methods used before, during, and after surgery. It explains: • ‘When using sutures, consider using antimicrobial triclosan-coated sutures (a type of suture designed to reduce the risk of surgical site infections), especially for paediatric surgery, to reduce the risk of surgical site infection’.
17. Our adviser confirmed B underwent an internal fixation procedure. This is a surgical technique used to secure tissue in place so it can heal properly. During the procedure, the skin was closed with monocryl sutures. These are dissolvable stitches that hold the tissue together after surgery to support proper healing. This works in line with NICE guidelines.
18. B’s medical records show that his wound was then closed externally using glue. No dressing was applied at the end of the surgery. In recovery, the wound was recorded as clean and dry.
19. After B returned to the ward, his medical records note early superficial bleeding and edge separation (where the edges of a surgical wound begin to separate from the surrounding tissue).
20. The records show that steri-strips (thin adhesive strips used to close surgical wounds) were applied. After the first application, there was some further bleeding, which required a second application of steri-strips. It is noted the second application successfully controlled the bleeding.
21. NICE guidance does not detail a specific skin closure method. Our adviser has explained that the risk of infection and cosmetic outcomes does not differ between the use of glue or sutures when closing a wound. Therefore, either choice is an appropriate method of skin closure in paediatric surgery.
22. Our adviser tells us although sutures do reduce the likelihood of the wound reopening, this is also a known risk of the procedure B underwent. We recognise this was very upsetting for B but taking into consideration NICE guidelines and our adviser’s advice, we cannot say the Trusts actions in using glue were inappropriate.
23. B’s medical records also show that no dressing was applied to the closure wound.
24. NICE guidelines state surgical incisions should be covered ‘with an appropriate interactive dressing at the end of the operation’.
25. Our Principles of Good Administration state that in some cases, where a different approach can bring a better outcome, public bodies can divert away from guidelines. If they do, they should always explain why.
26. The Trust detailed that dressings are not normally used over glue because they may interfere with bonding.
27. Our advisor tells us that although the absence of a dressing does not strictly follow NICE guidelines, the reason detailed by the Trust explaining why a dressing was not applied falls within reasonable professional practice.
28. Our adviser explains it is recognised that superficial dehiscence (where the edges of a wound partially separate) is a risk even when dressings are applied. B’s medical records show his wound healed without deep infection and there was no permanent physical harm, which indicates the procedure was completed appropriately.
29. We recognise the psychological distress B suffered. We want to reassure B and Mrs Q that B’s wound opening was not because of unsafe surgical technique.
30. We have found no indications of failings regarding the Trust’s closure of B’s wounds. For this reason, we will not be taking any further action on this part of the complaint.
Keeping B in recovery for too long
31. Mrs Q specifically complains that the Trust kept B in recover for a long time and by the time he returned to the ward, the wound was open and bleeding.
32. Mrs Q says B was wide awake after coming back from surgery. Mrs Q saying normally when B comes back from surgery, he’s sleepy and groggy, but on 6 October 2024, he was wide awake, and Mrs Q could hear him screaming.
33. B’s medical records show that he was kept in recover for approximately 20 minutes after the surgery and that safety checks were completed prior to B’s transfer to the ward.
34. B’s medical records also show that the wound was documented as clean and dry at this stage and distress was noted after B’s transfer where bleeding became apparent afterward. B’s medical records show that steri-strips were applied to B’s wound, and he was discharged.
35. There is no clinical guidance detailing how long a patient should be kept in recovery. Our adviser tells us that perioperative care (care provided before, during, and after surgery) requires a patient to be stable and evidence the wound is closed and not excessively bleeding.
36. Our adviser explains some patients react differently to anaesthetic and some children remain sleepy prior and some awaken suddenly.
37. Our adviser tells us that transfer to the ward after 20 minutes in recovery is not outside normal practice and bleeding emerging after agitation does not indicate a premature transfer. Furthermore, our adviser tells us that a minor wound ooze may become apparent after agitation or movement and that the management with steri-strips indicates recognition and response from the Trust.
38. We have seen no indications B was kept in recovery for longer than he should have been. As we have not seen any indications of failings here, we will not be taking any further action on this part of the complaint.
Conclusion
39. In summary, we are satisfied the Trust acted in line with NICE guidelines and in line with our principles in their care of B.
40. We are very sorry to hear about the stress B has suffered and how this has affected him. We hope our decision provides Mrs Q with assurance about B’s care and helps bring this matter to a close for him and Mrs Q.