Pressure ulcer care and treatment: First admission 17. Miss B says Mrs C had a small, nearly healed moisture lesion on her sacrum when she was admitted to hospital on 22 March. She says during this hospital admission, the pressure ulcer became significantly worse, became infected down to the bone, and contributed to Mrs C’s death from sepsis two months later.
18. Moisture lesions are skin damage caused by incontinence and can be caused by a failure to provide timely continence care to meet the patient’s needs. Mrs C had urinary incontinence managed with a long-term catheter and had been confined to her bed since fracturing her hip in September 2022.
19. Mrs C had regular visits from district nurses in the community, who provided her with monitoring of the catheter and support with any skin damage from her combined incontinence and immobility. The district nursing records note the presence of a small moisture lesion on the sacrum in December 2022, which was treated in the community. On 20 March 2023 this moisture lesion was noted to be discoloured and photographs were taken.
20. When the district nurse visited on 21 March, they noted issues with the catheter draining and were concerned Mrs C had signs of a urinary tract infection (UTI). Mrs C was admitted to hospital on 22 March for treatment of a UTI.
21. We looked at the standards relating to management of pressure ulcers in hospitals. NICE pressure ulcer guidance says: • carry out and document an assessment of pressure risk for adults being admitted to secondary care if they have a risk factor, for example: • significantly limited mobility • a previous or current pressure ulcer • nutritional deficiency • the inability to reposition themselves • significant cognitive impairment • offer adults who have been assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional • the skin should be checked for • skin integrity in areas of pressure • colour changes or discolouration • develop and document an individualised care plan for adults who have been assessed as being at high risk of developing a pressure ulcer, taking into account: • the need for additional pressure relief at specific at-risk sites • their mobility and ability to reposition themselves • offer adults with a pressure ulcer a nutritional assessment by a dietician or other healthcare professional with the necessary skills and competencies • encourage adults who have been assessed as being at high risk of developing a pressure ulcer to change their position frequently and at least every four hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required.
22. Our nurse adviser sets out the expectations for hospitals when a patient is admitted with skin damage. Any identified pressure ulcer on admission should be reported as an incident and noted as either community or hospital acquired. In addition, with any skin damage, nutritional, continence and repositioning needs must be assessed to encourage and support wound healing. They explain a nutritional assessment is important as this assesses a patient’s level of malnutrition which could affect wound healing, and any required interventions to support improving nutrition.
23. The Trust’s pressure ulcer policy says screening to assess for skin damage, and a pressure ulcer assessment, should be carried out within six hours of hospital admission. Screening and assessment should be reviewed on transfer to another ward, if the patient’s condition changes, or otherwise weekly.
24. The Trust’s policy refers to the use of PURPOSE-T tools. PURPOSE-T is a pressure ulcer risk assessment tool widely used within the NHS. For those patients admitted into emergency departments, skin checks and PURPOSE-T screening (a quick check to screen out patients clearly not at risk of pressure ulcers) should be done within an hour of admission. If the patient is deemed at risk of developing pressure ulcers, then a full PURPOSE-T risk assessment should be done.
25. NHS England says healthcare staff should record all patient safety incidents on their organisation’s local risk management system. NICE guidance on pressure ulcers explains pressure ulcers are classified into six categories: • Category 1 – non-blanchable erythema (red or discoloured skin that does not fade under pressure) • Category 2 – partial thickness skin loss • Category 3 – full thickness skin loss • Category 4 – full thickness tissue loss (skin plus the underlying tissue is affected) • Unstageable – depth of ulcer unknown • Suspected deep tissue injury – depth unknown
26. The Trust’s policy says all pressure ulcers that are identified as Category 2, 3 or 4, unstageable, deep tissue injuries and moisture associated skin damage must be reported on the Trust’s Datix system. All unstageable, deep tissue injury, mucosal ulcers and Category 3 or 4 ulcers must be referred to the Tissue Viability Nurse (TVN) service. TVNs are nurses who specialise in wound management and treatment, including pressure ulcers. There are no specific time frames for when a TVN referral should be made.
27. Mrs C’s initial assessment on admission to the Trust’s emergency department was recorded at 8.49am on 22 March 2023. The emergency department pressure ulcer assessment form, which we saw in the healthcare records, was not completed during her time in the emergency department. This is not in line with the Trust’s policy, which says skin checks and a PURPOSE-T screening should be done within one hour of admission to the emergency department. In Mrs C’s case this should have been done by 9.49am.
28. At 6pm an emergency department nurse noted multiple Category 2/unstageable pressure ulcers on Mrs C’s sacrum and a moisture sore in her groin. They noted they had completed a Datix report (a system of reporting patient safety incidents in the NHS) and applied a dressing. This is the first reference we could see to identification of any wounds on Mrs C’s sacrum, which suggests no skin checks were done until over nine hours after she was admitted. This is not in line with the Trust’s policy, which states initial skin checks should be done within an hour of the patient’s admission to the emergency department.
29. The Datix report, submitted at 6.10pm on 22 March, notes multiple grade 2 pressure sores to the sacrum and both buttocks, one unstageable, and moisture lesions in the groin area. The nurse recorded a PURPOSE T assessment had been completed and that Mrs C was awaiting a TVN review. From what we could see, the first PURPOSE T assessment was recorded on 23 March (by a nurse after Mrs C was transferred to the ward). We could not see evidence that a Purpose T assessment was done on 22 March.
30. The Datix report also stated Mrs C had a MUST (Malnutrition Universal Screening Tool, a national method of assessing a person’s risk of malnutrition) score of 0, but we could not identify any nutrition assessments to explain this. Mrs C’s son reported she had not been eating well for a few days and he had been struggling to get her to drink fluids.
31. Mrs C was transferred to a ward at 1.01am on 23 March, over 16 hours after she arrived in hospital. A ward nursing assessment done at 1.26am, which included skin assessments, noted a pressure ulcer on the sacrum. The nurse identified this as ‘Category 2/unstageable’ and logged a ‘red’ PURPOSE-T outcome (a red outcome should be logged with any pressure ulcer of Category 1 or above). The nurse noted they completed another Datix incident report at 1.45am, although we could not see evidence of a new Datix report.
32. The Datix investigation was completed on 13 April, after Mrs C had been discharged home. The outcome noted lessons to be learned included to ensure skin checks are carried out as soon as possible after arriving in the emergency department. It added skin assessments should be completed for all patients and the correct process followed when skin damage is identified. It also noted there was no harm to the patient from the incident. We set out at the end of this section why we do not agree with the investigation’s view there was no harm caused.
33. While the Datix incident report was appropriately completed, the Purpose T assessment and referral to the TVN should have been done within six hours of Mrs C’s admission. This is not in line with the Trust’s policy which says initial skin checks should be done within one hour of admission and a full skin assessment done within six hours of admission if skin damage is noted.
34. As Mrs C’s existing moisture lesion was initially assessed as ‘unstageable’, a referral should have been made to the TVN service on 23 March. This did not happen. The Trust acknowledged in its response to the complaint that there were errors in the completion of the Datix incident report. It said this error meant the Datix incident report was not sent to the TVNs, who were not alerted to the pre-existing moisture lesion when Mrs C was admitted.
35. Our nurse adviser says the skin damage that Mrs C was identified to have on the first assessment on 23 March required an urgent referral to the TVN team, and an immediate referral should have been made to the TVN service. Any delay to this should have been followed up and escalated.
36. A doctor referred Mrs C to the TVN service on 27 March. A TVN assessed Mrs C on 29 March, six days after the wound damage was first noted and seven days after she was admitted. The TVN’s review says they were asked to review an unstageable pressure ulcer to the sacrum and category 2 ulcers on the buttocks. The TVN noted an unstageable pressure ulcer and evidence of moisture-associated skin damage on the sacrum, with the surrounding skin pink and macerated (breakdown of skin due to prolonged contact with moisture). They also noted an unstageable pressure ulcer mixed with moisture associated skin damage on the right buttock. The TVN wrote a treatment plan for nurses to follow which included wound treatment and dressings with strict regular turning.
37. To help us consider whether the skin damage should have been escalated to doctors, we looked at what the relevant guidance says. Health Education England’s pressure ulcer guidance is targeted for nursing staff in hospitals and says:
• Inform a doctor if the pressure ulcer deteriorates: • There’s swollen skin on the ulcer • Pus coming from the pressure ulcer • Cold skin and a fast heartbeat • Severe or worsening pain • A high temperature of 38 degrees or greater
38. Our physician adviser notes the TVN’s review on 29 March did not indicate concern for infection in the wound at the time of their review. They say there is no indication from the TVN review that escalation of the pressure ulcer to a doctor was required.
39. The Trust’s policy states that skin risk assessments should be reviewed when the patient transfers to another ward. Mrs C was transferred to another ward on 25 March and again on 7 April.
40. The Trust’s response to Miss B’s complaint acknowledges that on 25 March, risk assessments and Purpose T assessments should have been reviewed when Mrs C was transferred to another ward, but this was not done. It acknowledges there are gaps in the nursing records relating to repositioning changes, and three days with no documented skin checks. We can see a wound care plan was started, noting a category 2/unstageable ulcer on the sacrum, but this was undated. Two entries were added to that wound care plan, on 27 and 31 March. On 31 March, a nurse noted the pressure ulcer was now category 3.
41. The Trust’s policy says if an existing pressure ulcer deteriorates (e.g. from a category 2 to a category 3) and changes category, a new Datix report should be completed. This means when the pressure ulcer was noted to have progressed to category 3, a new Datix report should have been created and a further referral to the TVN service made at that time. No further Datix reports were completed during this admission relating to pressure ulcers, despite the ulcers deteriorating during the stay.
42. The Trust acknowledges risk assessments were not reassessed on the third ward, when Mrs C was transferred on 7 April, although it says a new wound care plan was completed. The wound care plan for 7 April notes there was now a new category 2 ulcer on the buttocks, as well as the existing unstageable ulcer on the sacrum, with odour, and signs of infection due to green wound tissue. These had not been noted on the previous wound care plan. Two further entries were noted on that wound care plan, on 8 April and 11 April. However, another wound care sheet in the records, which did not have any patient names on it, had notes added on 10 and 11 April crossed out with ‘there is no sign of redness anymore’. This further wound care sheet is inconsistent with the other information in the healthcare records. It is not clear on what date the care plan notes were crossed out, whether this relates to Mrs C or another patient, and in any case this information that there was no longer any redness does not match with the other information we have in the healthcare records relating to 10 April.
43. A further referral was made to the TVN service on 10 April due to one of the wounds ‘leaking heavily’. As we have previously noted, this referral should have been done when the pressure ulcer was noted to have changed from category 2 to category 3 on 31 March. Mrs C was discharged home on 12 April without receiving a review from a TVN. We consider this issue further under the heading ‘Discharge on 12 April 2023’.
44. There is no clear documentation of when care planning for the ulcer present on admission started, and what care interventions were provided prior to the TVN’s assessment on 29 March. The clinical records show evidence that wound assessments, planning and evaluation of care plans started five days after admission, with no TVN visiting Mrs C for seven days after her admission. This is not in line with the Trust’s policy, NICE pressure ulcer guidance or NHS England pressure ulcer guidance.
45. Care planning and interventions should have been started once the moisture lesion was first noted, which should have been on 22 March, and a TVN should have reviewed Mrs C sooner. We could see no clearly documented care provided in relation to pressure ulcers between 22 and 26 March 2023.
46. We know Mrs C had an existing discoloured moisture lesion on her sacrum on her admission to hospital. She also had limited mobility, cognitive impairment and had not been eating or drinking as usual for several days. These are all risk factors for developing pressure ulcers, and should have been considered within Mrs C’s assessments for her risks of skin damage.
47. A referral was made to the dietician to provide nutritional support to Mrs C during the admission, but she was not seen. We know this as it is mentioned by the doctor who wrote the discharge report. There is a note that a nurse referred Mrs C to dietetics on 8 April, but no mention of any nutritional or dietetic referrals before then. We could not see any explanation why a dietician did not see Mrs C during her admission, considering poor nutrition is a risk factor in the development and deterioration of pressure ulcers.
48. In summary, Mrs C should have had her initial skin checks within one hour of her arrival in hospital, by 9.49am. A full pressure ulcer risk assessment should have been done within six hours of her admission, by 2.49pm that day. As it was, Mrs C did not receive any skin checks or pressure ulcer risk assessments until over 16 hours after first arriving in hospital.
49. During the first five days of Mrs C’s admission, there was poor documentation of wound care and treatment plans. The initial skin checks and the pressure ulcer assessments were done well outside the timeframe set out in the Trust’s policy. There was a delay of four days before a referral was made to the TVN service. There is a gap of three days during which we could see no evidence of specific pressure ulcer management, skin checks or care, when care should have been provided daily throughout the day. Two hourly repositioning was not followed, with gaps of 12-24 hours between repositioning during the admission. No Datix report or referral to the TVN was made when the pressure ulcer was noted to have deteriorated on 31 March, and a TVN did not review Mrs C before she was discharged home. This was despite the deteriorating pressure ulcer being noted as category 3/unstageable when Mrs C was discharged home.
50. Mrs C was clearly at risk of pressure ulcers due to her existing moisture lesion, incontinence, immobility and poor nutrition due to illness, and continence and nutritional assessments should have been done. We could see no evidence in the clinical records of continence care or planning for managing Mrs C’s incontinence, other than a note she had a long-term urinary catheter in place. As incontinence is a risk factor for developing skin damage, this should have been included as a factor in assessing Mrs C’s risks and putting in place preventative measures. We also could see no evidence of a robust nutritional assessment, a referral was not made to a dietician until four days before Mrs C was discharged home, and she received no specialist nutritional input.
51. We have seen multiple failings in pressure ulcer management from Mrs C’s admission on 22 March, to her discharge on 12 April. We turn now to consider the impact of these failings.
52. Mrs C had a urinary catheter to manager her incontinence. While the management of the urinary catheter was poorly recorded, our physician adviser says that Mrs C’s incontinence is unlikely to have contributed to the pressure ulcer developing. They do say it is likely the other failings in pressure ulcer management and care set out above contributed to the failure of the existing ulcers to heal and caused them to deteriorate.
53. We take into account Mrs C had other factors that put her at risk of her pressure ulcers deteriorating. She was physiologically vulnerable due to underlying conditions not linked to the suboptimal care provided to manage her pressure ulcers. These include her severe frailty, acute illness (even with appropriate treatment), cognitive impairment and her nutritional status on her admission. All of these factors contributed to her skin integrity, risk of developing pressure ulcers and wound healing ability. For these reasons, it is not possible to state how far the poor care contributed to the failed healing and deterioration of the pressure ulcers, or to state these would not have developed or deteriorated during this admission.
54. With that said, it is clear these failings in care did put Mrs C at risk of poor healing and deterioration of the initial moisture lesion, and put her at risk of further damage and infection. On balance, we find that the poor care was a key factor in the deterioration of the pressure ulcers and put Mrs C at risk of developing osteomyelitis. It is not possible to state definitively that the osteomyelitis would not have developed without the poor care, due to the other contributing factors we have set out.
55. Miss B says it was extremely distressing to her and her family to see how much pain her mother was in. She says this has affected her and her family’s bereavement, causing them all significant distress. Miss B says she continues to be affected by the memories of her mother in so much pain towards the end of her life.
56. We note the Trust acknowledged in its response to the complaint a number of failings in pressure ulcer management and care. These included errors in the initial referral to the TVN service, risk assessments not being done on transfer to the first ward, Purpose T not being reassessed on that ward, and a gap of three days with no skin checks recorded. It acknowledged pressure ulcer assessments and documentation had not been done to its expected standards. The Trust told Miss B it has made improvements to ensure staff complete care plans and assessments, and to prevent mistakes with TVN referrals from happening again.
57. The Trust initiated Pressure Ulcer Root Cause (RCA) Analysis reports during the second admission. The RCA reports focussed on the Datix incident reported on 23 March, during Mrs C’s first admission. The RCA report identified a number of failings in pressure ulcer management during the first admission. These included that the initial Datix report did not trigger a TVN referral as it was submitted as a Category 2. When the Purpose T risk assessment was done on 23 March, no wound care plan was initiated and no referral to the TVN was made then. The RCA report identified that 2 hourly repositioning was not followed, with gaps of 12-24 hours between repositioning and 3 days during which no skin checks were documented. Also identified was that Purpose T risk assessments were not done when Mrs C was twice transferred to other wards.
58. The RCA reports also noted that the pressure ulcer had deteriorated to Category 3 on 10 April, and a re-referral was made to the TVNs, but this was added to the closed referral and so was not received by the TVN team. It identified incomplete documentation, failure to follow the Purpose T red pathway, incomplete wound care plans, missed opportunities for TVN assessment and review and a failure to delay discharge from the first admission until the TVN review was completed as contributory factors. An action plan was created but no actions were recorded. The RCA report acknowledged that Mrs C had died as a direct result of necrotising fasciitis, a rare and life-threatening infection of the deep layers of the skin, as a result of the pressure ulcer.
59. We think there is more the Trust can do to put right the impact of the failings in pressure ulcer care and prevent them happening again. We set these out in recommendations to the Trust at the end of this report.
MRI scan of the hip 60. Miss B complains that a planned MRI scan of the hip was not done during the first admission. She says if it had been done, it may have shown developing osteomyelitis (an infection in the bone) at the time.
61. The records show a doctor wrote on 24 March they were advised by orthopaedics to request a non-urgent MRI scan of the right hip. The MRI scan was planned specifically in relation to concerns about hip pain, in relation to a hip replacement Mrs C had in September 2022.
62. A radiologist at the Trust advised that an MRI scan was not the ideal method to view the hip, due to hip replacement metalwork distorting the MRI images, and recommended an X-ray of the hip which was done instead. An X-ray of the hip was done on 29 March.
63. Our physician adviser said there was no clinical suspicion of osteomyelitis at that time, so there was no indication to do an MRI scan of the pelvis.
64. We recognise Miss B’s concerns that osteomyelitis may have developed during the first admission and that the MRI scan would have shown this. We have seen no evidence to suggest that osteomyelitis had developed during the first admission, and we consider this further under the heading ‘discharge on 12 April 2023’. We have taken into account the MRI scan was initially considered to check Mrs C’s hip replacement and not specifically to check for signs of osteomyelitis.
65. We have not seen failings in the decision not to proceed with an MRI scan of the hip during Mrs C’s first admission.
Discharge on 12 April 2023
66. Mrs C was discharged home from hospital on 12 April 2023. Miss B says she arrived home with a very large pressure sore on her sacrum, which had been a small, healing moisture lesion on her admission on 22 March. She thinks it was inappropriate to discharge her mother from hospital with such a large pressure sore, and has concerns it may have been infected at that time.
67. DHSC discharge guidance sets out the medical criteria for patients who are not fit to be discharged from hospital. The healthcare records show Mrs C did not meet any of these criteria on the day of her discharge home and so was medically fit for discharge.
68. Our physician adviser agrees, from the information in the healthcare records, it was appropriate to consider Mrs C medically fit for discharge. The catheter-associated urinary tract infection that she was admitted with had been treated, with infection markers steadily improving during the admission. Blood tests and observations done before the discharge did not indicate acute illness or infection at that time. There was no ongoing indication for treatment that required a hospital admission. From a multidisciplinary perspective, the discharge was planned with input from the physiotherapy and occupational therapy teams, and with involvement of Mrs C’s family.
69. We note Miss B’s concerns that the pressure ulcer could have been infected when Mrs C was discharged home. We take into account nurse’s concerns on 7 and 10 April about leaking and potential infection of the wound. Our physician adviser explains that white cell count and C-Reactive Protein, both markers for infection used in blood tests, would have risen by 12 April if there was a significant infection in soft tissue or the bone, and this had not happened. Open skin wounds can leak fluids regardless of whether infection is present, and observations done before Mrs C was discharged home do not show signs of systemic illness.
70. We have also taken into account Mrs C received regular pressure ulcer care from the community district nurses and community TVN (set out in more detail below under the heading ‘community nursing care’). The community nursing records do not show concerns about pressure ulcer infection or a risk of developing osteomyelitis until 11 May, one month after Mrs C had been discharged home, and shortly before she was readmitted to hospital on 14 May.
71. This means it is unlikely there was a serious wound infection at the time Mrs C was discharged home on 12 April.
72. The Trust’s discharge policy explains that a patient is medically fit for discharge when they no longer need inpatient medical care or treatment in a hospital setting. This does not mean they no longer need medical care or treatment, but this could appropriately be provided in a community setting. The decision that a patient is medically fit for discharge is usually made the consultant or medical team responsible for the patient. We have not seen evidence to dispute the decision that Mrs C was medically fit for discharge on 12 April. However, we take into account other factors that may have affected her discharge home on that day.
73. On 10 April, a nurse recorded the unstageable pressure damage had evolved to a category 3 pressure ulcer and was leaking fluid heavily. A referral was made to the TVN team. The Trust explained in its response to the complaint that this referral was not actioned as it was added to the previous closed referral. A further referral to the TVN team was made on 11 April. However, when the TVN attended the ward on the morning of 12 April, Mrs C had already been discharged home.
74. The Trust’s policy includes actions required when discharging a patient with pressure damage. The policy states all patients with pressure ulcers should be discharged with a wound care passport to ensure continuity of care in the community. The Trust told us it does not keep copies of wound care passports in the patient’s records, but this would have been sent with the ambulance crew when Mrs C was transported home. We could not identify a copy of the wound care passport in Mrs C’s community records.
75. The Trust’s policy also states the care provider who will be taking over the patient’s care must be given information of the pressure ulceration before discharge. We can see no evidence of any contact made with the community District Nursing team to inform them of the pressure ulcers before Mrs C was discharged home.
76. Our nurse adviser says it would have been appropriate for Mrs C’s discharge to be delayed until she saw the TVN, and to escalate the request for an urgent TVN review to avoid prolonging her stay. We take into account the Trust recognised the discharge should have been delayed when it completed a Root Cause Analysis (RCA) investigation into this incident. We discuss the RCA report in more detail in paragraphs 57-58 of this report.
77. The doctor’s notes in the healthcare records, in the days leading up to Mrs C’s discharge, do not make any reference to concerns about the pressure ulcer or the referral to the TVN service. It appears there was a lack of communication between the medical and nursing teams in relation to ongoing concerns about the pressure ulcer. Our physician adviser agrees that, had the medical team been made aware of this, the discharge home should have been delayed until the TVN had reviewed Mrs C. If there were concerns about significant delays to the discharge, an urgent outpatient assessment could have been requested to allow Mrs C to go home that day.
78. We do not think the decision Mrs C was medically fit for discharge on 12 April was inappropriate. However, the discharge should have been delayed until she had been reviewed by the TVN. A TVN attended the ward on the morning of the discharge date, and we could not see any explanations why Mrs C was sent home before the TVN review. There would not have been a significant delay if the ward had waited for the TVN to review Mrs C that day before she went home.
79. Because no TVN review took place, we do not know whether any further treatment was needed for the pressure ulcers before Mrs C was discharged home. There was also a missed opportunity for additional information about the state of the pressure ulcer to be included in Mrs C’s discharge notes for the community nurses to taking over the care.
Community nursing care 80. Miss B has not complained about the care and treatment provided to Mrs C in the community to manage her pressure ulcers. However, information from the community healthcare records is relevant to help us understand what happened with the pressure ulcers between Mrs C’s discharge home and her return to hospital on 14 May.
81. Mr D, who lived with Mrs C, told us that when she came home, the district nurse who visited was angry and annoyed to see the condition of the pressure ulcers, which had significantly worsened from before her hospital admission. Mr D told us Mrs C screamed in pain every time the carers moved her.
82. A district nurse visited Mrs C on 13 April. They noted the wound had exacerbated whilst Mrs C was in hospital and was now an unstageable wound of at least Category 3. They recorded evidence of deterioration of the existing wound prior to the hospital admission. The district nurse discussed this with the community TVN, completed an incident report, and increased the frequency of district nurse visits.
83. The community TVN noted Mrs C had been admitted to hospital on 22 March with urinary retention and a moisture lesion to sacrum, and was discharged home on 11 April with an unstageable category 3 pressure ulcer. On 18 April the community TVN raised a request with the district nurses for a safeguarding referral to the local authority, due to deterioration of the wound whilst in hospital care.
84. A district nurse sent a safeguarding referral to the local authority’s safeguarding team on 20 April. On 26 April the local authority decided no further action was required. It said when Mrs C was admitted to hospital, all necessary risk assessments were completed on noting the deterioration. It said the deterioration in pressure ulcers was due to Mrs C entering the end of her life rather than neglect.
85. Mr D told us he received a telephone call from the local authority’s safeguarding team. He says the local authority told him that it was nobody’s fault his mother had developed the pressure ulcers. He says this gave him and Miss B concerns nobody was taking responsibility for the deterioration of Mrs C’s wound.
86. On 11 May, the community TVN reviewed Mrs C. They noted the pressure ulcer had deteriorated and that Mrs C was at high risk of osteomyelitis as the bone could be seen. They recorded there were no current signs of infection but this was likely to change, and alerted Mrs C’s GP to the risk of her developing osteomyelitis.
87. On 14 May, the district nurse visited Mrs C at home. Mr D told them Mrs C was taking in very little fluids and was struggling to swallow, and had increased confusion. The district nurse arranged an ambulance to take Mrs C to hospital later that day.
Pressure ulcer care and treatment: Second admission 88. Mrs C was readmitted to hospital at 7.22pm on 14 May. We know she had a large existing pressure ulcer on her readmission. In line with the Trust’s policy, we would have expected to see skin checks undertaken within an hour of her admission, and a full pressure ulcer assessment within six hours.
89. The pressure ulcer was first noted by a nurse at 9.50pm that day when they checked the pressure areas. They noted a large Category 4 ulcer on the sacrum. A Datix report was completed at 11.20pm. We can see a pressure ulcer assessment was completed during this time, but we could not see evidence a wound care plan was started until 16 May.
90. A nurse noted in the records at 4.15pm on 15 May that a referral to the TVN team had been made. The TVN reviewed Mrs C on 16 May. They noted Mrs C had a Category 4 ulcer with bone exposed, and slough over the top, which was leaking and smelly. Their plan included initiating the Purpose T red pathway, specific treatment for wound, and to discuss potential osteomyelitis with the consultant. This appears to be when the first Purpose T assessment was done for this admission. The TVN completed a wound care plan with instructions for daily treatment of the wound.
91. The consultant reviewed Mrs C on 16 May. They noted the large pressure ulcer to be the potential source of infection and planned an MRI scan to identify potential osteomyelitis.
92. The standards and guidance relating to pressure ulcer care which we considered for the first admission also apply here. This means that, in line with NICE pressure ulcer guidance, we would expect to see continued skin assessments to review for any signs of new skin damage. We would also expect to see nutritional assessments and evidence of continence assessments and continence care.
93. We can see there were delays in the initial skin checks, which should have been done by 8.22pm on the day of admission. While a full pressure ulcer assessment and a Datix incident report were completed shortly afterwards, we could not see evidence of a Purpose T risk assessment or wound care plan being started until the TVN reviewed Mrs C two days after her admission.
94. We could see no evidence of nutritional assessments, continence care or ongoing skin assessments done during the second admission. This is not in line with NICE guidance which stresses the importance of managing nutritional and continence needs as part of the healing process for moisture lesions and pressure ulcers. A continence assessment should have been done to assess Mrs C’s risks in relation to her personal care and hygiene needs due to incontinence. We could also not see any evidence of continued skin assessment to review for any signs of new skin damage.
95. We found further failings in pressure ulcer management during Mrs C’s second admission. The initial skin check was done two and a half hours after Mrs C’s admission, longer than the one hour timeframe required by the Trust’s policy. The full skin assessment and a Datix report were completed within the required timeframe of six hours. A wound care plan should then have been started, but we could not see evidence of any wound care plan until two days later. A referral to the TVN service should also have been made when the Datix report was submitted, but we could not see evidence of this until the following day. A Purpose T assessment should have been done on the day of admission, but this was not done until the TVN reviewed Mrs C two days after her admission. Nutritional and continence assessments should also have been done, but we could not see evidence any were done during this admission. Mrs C’s skin should have been regularly assessed for any signs of new skin damage. Again, we could not see evidence of this during this admission.
96. In summary, we have seen failings in the management of Mrs C’s moisture and pressure ulcers throughout both the first and the second admission. These likely contributed to the pressure ulcers becoming worse, deteriorating to the bone and causing Mrs C significant pain, which was very distressing for Miss B and her family to witness.
97. We note the Trust acknowledged, in its response to Miss B, that during the second admission digital care plans and assessments were not documented as they should have been. The Trust indicated it had taken steps to learn from this and improve its services.
98. We set out a number of recommendations at the end of this report to put right the impact on Miss B, and to further improve the Trust’s services to prevent this from happening again.
Delay in diagnosing and treating osteomyelitis 99. Miss B raised concerns that her mother may have been discharged home on 12 April with signs of osteomyelitis, an infection of the bone, due to the severity of the pressure ulcer.
100. As we previously noted, we have not seen evidence that Mrs C was discharged home with an infected pressure ulcer on 12 April. From the district nursing records, we can see on 11 May the community TVN reviewed Mrs C’s wound. They raised concerns with Mrs C’s GP about the risk of osteomyelitis, as the wound had deteriorated down to the bone, but at that stage, they did not see evidence of infection. We have not seen evidence to suggest Mrs C had developed osteomyelitis during the first admission.
101. Mrs C was readmitted to the Trust on 14 May. During the first two days of her admission, other sources of infection such as urinary or abdominal were considered. On 16 May, the TVN reviewed Mrs C. They noted the category 4 pressure ulcer and discussed this with the consultant, who identified it as a potential source of sepsis. The consultant appropriately requested an MRI scan of the pelvis to identify any potential osteomyelitis.
102. The MRI scan was done on 19 May. This scan confirmed Mrs C had osteomyelitis. There is no national guidance setting out how urgently an MRI scan should be done for suspected osteomyelitis. Our physician adviser explains this scan should be considered an urgent requirement, which they would expect to be done within 24-72 hours.
103. Treatment with appropriate antibiotics was started on 15 May. The choice of antibiotic was guided by clinical suspicion of osteomyelitis and the results of blood cultures on admission. A swab was taken of the pressure ulcer on admission, and when the results were available, the antibiotics were reviewed and considered again once osteomyelitis was confirmed.
104. Our physician adviser explains that Mrs C’s blood monitoring showed a positive response to the antibiotics once they were started, and the time taken to do the MRI scan and confirm the presence of osteomyelitis did not affect the treatment plan.
105. We have not seen any evidence there was a delay in the diagnosis of osteomyelitis, and appropriate antibiotics were provided to treat this both before the diagnosis was made and once osteomyelitis was diagnosed.
Delirium and dementia 106. Miss B says Mrs C was suffering from delirium as a result of infections, and this was inappropriately dismissed as dementia. She says that before her hip fracture in September 2022, Mrs C had her mental state assessed by a GP and no diagnosis of dementia was made then. She describes her mother as ‘pleasantly confused’ before the hip fracture.
107. Mrs C did not have a formal diagnosis of dementia before her hospital admissions in March and May 2023. A formal diagnosis of dementia is ideally made in an outpatient or community setting during a period of stable health, so that detailed mental test assessments can be performed. In situations where a person has had repeated illness and hospital admission, this is not achievable. The next best option is to reach conclusions from taking the patient’s history from those close to the patient, clinical assessment, and review of the clinical records.
108. We can see from the Trust’s response to the complaint that, when Mrs C was admitted in September 2022 for her hip fracture, doctors were concerned she was showing signs of dementia and asked her GP to refer her back to the memory clinic.
109. The British Medical Association provides up to date guidance on assessing patient’s capacity to make decisions about their care, based on the principles set out in the Mental Capacity Act 2005. This sets out that capacity for decision-making in healthcare is task specific and should be assessed for each decision individually. Any reasons why capacity is in doubt should be recorded in the patient’s clinical records, as well as details of any assessments of capacity and the outcome. Where a patient is found to lack capacity for a decision about their care, clinicians must make decisions in that person’s best interests.
110. This may include, in practice, brief or detailed notes in the clinical record. There is evidence that Mrs C’s capacity to consent to interventions or examinations was considered during the March to April admission, with notes made that Mrs C was at times confused and disorientated, and that decisions were made in her best interest due to cognitive impairment.
111. On 16 May a consultant geriatrician spoke with Miss B and Mr D to discuss Mrs C’s background of cognitive decline. They noted memory problems had started over five years previously with steady deterioration, and Mrs C had delirium on admission on 22 March. The consultant explained it was very likely Mrs C had undiagnosed dementia and was at that time in the advanced/end stage with acceleration of her decline ongoing from her hip fracture in September 2022. The consultant explained Mrs C was now severely frail and unwell, with delirium on a background of dementia, acute kidney injury, and infection.
112. A formal mental capacity assessment was done on 22 May 2023, in relation to Mrs C’s capacity to consent to nasogastric tube insertion to provide nutrition.
113. The clinical records show various terms were used during the two admissions to describe Mrs C’s state of mind. These included hypoactive delirium, confusion, dementia and undiagnosed dementia. Our physician adviser says, from their review of the clinical records, that these are all correct and appropriate descriptions of Mrs C’s condition and mental state. They say Mrs C is likely to have had dementia with episodes of delirium. They confirm a consultant geriatrician is a suitable specialist to make this assessment in these circumstances.
114. Miss B says she and her family do not accept that their mother had end stage dementia at the time of these events. She said before Mrs C’s fall in September 2022, she had been active, able to dance and to read poetry.
115. We note the term ‘end stage dementia’ is not recorded in Mrs C’s clinical notes or in the Trust’s response to the complaint. We can see that ‘advanced’ and ‘advancing’ dementia were terms used during Mrs C’s second admission in May, but not during the first admission.
116. Our physician adviser explains dementia is a broad condition that develops over a long period of time. A person who has dementia does not necessarily experience full cognitive decline and may still be able to read and write poetry. Dementia and the decline of cognitive abilities can accelerate due to other health factors. These may include frailty, such as may be caused from mobility issues due to a fractured hip, and infections. People with dementia are more likely to experience episodes of delirium, and when they recover from the delirium, they do not necessarily recover their baseline cognitive function. This means that after each episode of delirium, the dementia may decline further.
117. We understand Miss B’s views that she and her family members did not see evidence that Mrs C had significant signs of dementia before the events complained about. We know it can be difficult for family members to accept that a person has worsening dementia. We also understand her view that her mother’s delirium was mistaken for dementia.
118. Nevertheless, it is likely that Mrs C did have some level of dementia at the time of these events, which became worse with her increasing frailty and each episode of delirium.
119. We have not seen any failings in the decisions made that Mrs C likely had developed dementia as well as having episodes of delirium.
DNACPR and end of life decisions 120. Miss B says her concerns about the Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) form are not about the decision made not to resuscitate, which she understood, but with the reasons recorded for the decision. Her concerns lie with seeing a DNACPR form listing the reason not to resuscitation as ‘demented’, a term she found offensive and outdated. Miss B also said her mother was never formally diagnosed with dementia. She remains concerned her mother was dismissed as ‘end of life’ during both admissions.
121. The General Medical Council (GMC)’s definition of end of life care says that patients are approaching the end of life when they are likely to die within the next 12 months. This includes people with advanced, progressive incurable conditions and those with general frailty with co-existing conditions. It also includes those with existing conditions if they are at risk of dying from a sudden acute crisis in their condition.
122. The GMC’s ‘Good Practice in end of life care’ says where a patient lacks capacity, doctors must discuss the DNACPR decision with others close to the patient (such as family) and explain the reasons it is not appropriate or practical to resuscitate. This should be discussed at the earliest practical opportunity.
123. There were two DNACPR forms completed for Mrs C. The first form was completed during Mrs C’s earlier admission in September 2022 to treat her for her hip fracture. The form noted CPR would not be beneficial to Mrs C for the reasons of ‘age, frailty, demented, AF (atrial fibrillation) and PE (pulmonary embolism). Added to the form was that this decision had not been discussed with the patient due to ‘dementia’, and the doctor had been unable to get hold of her next of kin and had tried to contact them twice.
124. The Trust says in its response to the complaint that the DNACPR form had been cancelled as ‘family were not in agreement’. Mr D said nobody from the Trust ever discussed DNACPR decisions with him or his siblings. He found out a DNACPR form had been completed in September 2022 as a copy of this form was sent home with his mother after her discharge from that admission. He was unhappy to see the word ‘demented’ listed on that form as the reason for the DNACPR decision, so he rang the Trust to complain about the use of the term ‘demented’ to describe his mother on the DNACPR form. He said he did not discuss the DNACPR decision itself, and Miss B confirmed the decision not to resuscitate her mother was not of concern, but the use of the term ‘demented’ as the reason.
125. The second DNACPR form was completed on 16 May 2023. This stated that CPR would be of no clinical benefit because of the following medical conditions: severe frailty, lack of physiological reserve. This has not been discussed with the patient. Reason: delirium on background of dementia. The doctor noted they had discussed this with two of Mrs C’s children that day.
126. Our physician adviser agrees with us the use of the term ‘demented’ is old-fashioned and we think this is a clumsy use of language. However, dementia is an appropriate factor to inform a decision not to resuscitate someone. Dementia is a contributing factor to a person’s physical frailty, functional deterioration and death. It is one of many chronic diseases that reduce the likelihood of CPR being successful.
127. Our physician adviser says it would have been good practice to implement or reinstate a DNACPR form during the March-April admission, in view of Mrs C’s severe frailty that would put her at risk of sudden deterioration and death.
128. We have not found the decisions to put in place a DNACPR form for Mrs C were inappropriate. As we have previously explained, dementia is an appropriate factor to consider when making this decision, and we have not found it inappropriate that Mrs C was thought to have developed dementia at the time of the events.
129. We agree with Miss B that the use of the term ‘demented’ was inappropriate and we can understand how this could have caused her and her family offense. However this, by itself, is not serious enough for us to consider a failing in the completion of the DNACPR decisions.