A practice in the Hillingdon area

3. Mr A complains about the treatment the Practice gave to B on 21 October 2021. He says the Practice failed to close the wound on B’s head injury and the doctor did not warn the family about what to do if the wound stayed open.

4. Mr A says B has been left with an unsightly scar and gap in his head. He says B may need scar correction surgery in future.

5. Mr A would like financial compensation for B, to put towards any future surgery he may need.

6. B was assessed at the Practice’s urgent treatment centre (UTC) by a triage emergency nurse practitioner (ENP).

7. The ENP did an initial assessment and arranged for B to have a consultation with a doctor. The doctor assessed B and cleaned his wound. He treated the wound with glue and steri strips (thin, sticky bandages that work like dissolvable stitches). The doctor gave B’s mother a leaflet about head injuries to take home.

8. When Mr A realised the wound was not closing up properly, he contacted B’s doctor to arrange an appointment. He says B’s doctor was concerned the wound had already healed up but the skin had not closed up together as expected. The doctor referred B to the paediatric craniofacial team (specialising in the skull, face and jaws) at a local hospital.

9. B saw a plastic surgeon in May 2022. The plastic surgeon gave scar management to allow natural improvement, which his genetics will determine. He discharged B from his care. Mr A says he has been treating B’s forehead daily with silicone scar treatment gel to help with the healing. This is still ongoing.

Treatment to close the wound

13. Before we decide if we should do 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 done this and have not seen any signs that something went wrong.

14. The NICE guidance on ‘Lacerations’ says tissue adhesives (glues) can be used to close wounds that:

• are clean, non-infected and small (5cm or shorter) • have edges that lay easily side by side without leaving any dead space • are not subject to excessive flexing, tension or wetting • are not in a hair-bearing area • are not a result of mammalian bite (for example, dogs or cats).

15. The records of B’s wound show his injury met the criteria for gluing. The records note the wound was 1cm long, approximately 5 to 7 mm deep and the ‘edges close nicely’. The wound was cleaned and the records do not suggest any signs of infection. The wound was on B’s forehead and this is not an area where there is a lot of movement. It was not in an area with hair and the injury did not happen because of a bite.

16. NICE guidance on ‘Lacerations’ also recommends using skin-closure strips (steri strips), which the Practice applied as well as the glue. NICE advises these can be ‘effective for closing small, simple lacerations [cuts] in low-tension areas with well approximated edges’ (edges coming neatly together). The records of B’s wound say it was a small, simple wound. It was appropriate to use steri strips in line with NICE guidance.

17. We asked our adviser about the use of glue and steri strips. They said it is not detailed in NICE guidance, but these treatments can be used together and this is not uncommon. The NHS website says ‘it [glue] can be used on its own or with stitches or adhesive tape’. The glue can be used to seal the wound and the strips for extra support to keep the edges placed together and for protection.

18. Mr A thinks B may have needed stitching or another type of treatment to close his wound. We also checked with our adviser about using stitches or staples instead.

19. Our adviser highlighted that the NICE guidance says stitches are preferred for wounds longer than 5cm, or shorter than 5cm when the wound:

• needs careful approximation, for example, lacerations that cross skin tension lines or span delicate structures (such as the eyebrow or lip) • is subject to excessive flexing and tension (such as over joints), or excessive wetting.

20. Surgical staples are an alternative to stitches, but they are used for unclean wounds because they allow for drainage, on the scalp or extremities such as hands and feet. B’s wound did not meet the criteria for stitches or staples. The NICE guidance advises surgical staples give a poorer cosmetic result.

21. We are satisfied the Practice treated B’s wound in line with NICE guidance and have not seen any signs of a failing.

Advice given to the family

22. When we decide if we should do a detailed investigation of a complaint, we also look at whether there are signs the events complained about had a negative effect on the person, which the organisation has not put right. Having done so, we do not think this was the case.

23. The NHS website page ‘How do I care for a wound treated with skin glue?’ advises most wounds closed with skin glue will heal normally, but you should seek medical attention if:

• your wound splits open or starts to bleed • you think your wound may be infected (red, swollen, pain or soreness, blood or pus leaks, you have a high temperature and feel shivery).

24. This NHS guidance advises to contact your GP or practice nurse for advice, or go to an NHS walk-in centre. The NICE guidance on ‘Lacerations’ also recommends this, adding that advice should be given on pain relief (paracetamol or ibuprofen).

25. B’s records say ‘patient given written or verbal advice…wound closure…mum provided with head injury information leaflet and advice given for wound care. OTC analgesics recommended if needed’.

26. The Practice’s head injury leaflet includes information about signs to look out for such as vomiting, visual disturbance and dizziness. While this is not specific to wound care, it also says if you have concerns that your child’s condition is worsening (or it is not improving in the way that would be expected), you should seek medical advice as follows:

• contact your own registered GP practice • phone 111 outside of GP opening hours • if you are unable to get advice from the above and have urgent concerns, go back to the urgent treatment centre or A&E • call 999 if there are concerns of life-threatening illness or injury .

27. We do not know exactly what wound care advice the Practice gave verbally and specifically what, if anything, it told B’s parents to do if the wound stayed or split open. We can see the Practice gave a leaflet with information on getting further medical advice.

28. We know Mr A did what the NICE and NHS guidance recommended, as he took B to see his doctor when he was concerned. If the Practice had given specific advice, the outcome would have been the same and Mr A would have taken the same action.

29. In summary, we are very sorry to hear B has experienced a poor outcome and scar and the wound has not healed as expected. We have not seen any signs the Practice got things wrong when treating B’s wound. We cannot see that if the Practice had given any better advice, it would have led to B avoiding scarring. Unfortunately, sometimes scarring like B has experienced cannot be avoided from injury, despite appropriate treatment. We could only ask the Practice to take action to put things right if we thought its actions led to a worse outcome for B. We cannot say this was the case.

30. We know this is not the outcome Mr A was hoping for and our decision does not take away from the worrying experience he, B and the family had. We hope our decision gives Mr A some reassurance about the treatment B had and that he did the right thing in contacting B’s doctor when he became concerned.

1. The Parliamentary and Health Service Ombudsman has carefully considered Mr A’s complaint about how a practice in the Hillingdon area (the Practice) treated his son, B. It is clear this has been a worrying time for Mr A and we understand why he asked us to look at his complaint.

2. We are satisfied the Practice treated B’s wound correctly. The Practice may not have got everything right with its communication and the wound advice it gave, but we have not seen signs that this had a negative effect on B or Mr A.