Northern Lincolnshire and Goole NHS Foundation Trust

3. Mrs V complains the Trust left a blue internal suture in her abdomen when it performed a caesarean (c-section) on 17 March 2025. She also complains Trust staff did not have a clear understanding on how to care and treat her wound whilst she was readmitted as an inpatient later in March 2025.

4. Mrs V tells us the impact of the blue suture being left in her abdomen caused an infection above her c-section and resulted in her being admitted into hospital on IV antibiotics away from her newborn son. She tells us it was difficult for her to bond with her newborn son in his first six weeks of life.

5. Mrs V also tells us she lacked faith in the Trust’s ability to appropriately care and treat her at the time. She says the conflicting advice from staff was distressing for her.

6. By bringing her complaint to us, Mrs V is seeking an apology, acknowledgement of the impact the Trust’s actions has had on her, service improvements and a financial remedy.

7. What follows is a brief summary of events to provide context to the complaint. We do not include every detail as all parties to the complaint are aware of these.

8. Mrs V had an emergency caesarean on 17 March 2025 following a failed induction. Once her c-section had been closed it had a PICO dressing applied (a type of single use dressing). It is reported her midwife remove the dressing on 24 March 2025 and it was then Mrs V noticed the cellulitis.

9. The following day she went to her GP who prescribed antibiotics. On 27 March 2025, Mrs V noted blistering started to appear on her abdomen and the next day it developed into an open wound.

10. Mrs V went to maternity triage the same day where she was admitted and given IV antibiotics. We understand the wound worsened over the weekend and she was told tissue viability (TVN) did not work at the weekend and she would need to wait until Monday.

11. On Tuesday 1 April 2025, TVN saw Mrs V, dressed her wound and provided the midwives with instructions to care for Mrs Y’s wound. The following day, Mrs Y was discharged with oral antibiotics and transferred into the care of her GP for wound changes.

12. She says the wound slowly began getting smaller but it still had not healed completely. On 17 April 2025, during her dressing change at her GP practice, she says the nurse spotted a blue internal suture embedded in the wound which she had not been seen before. She says the nurse removed the suture, cleaned the wound and redressed it.

13. Mrs V believes the suture caused the infection and the wound in her abdomen and was the reason her wound had not healed at that point. During complaint handling the Trust says the c-section was a routine closure. It says the rectus sheath (a tough fibrous compartment in the abdomen) was closed with a loop PDS (polydioxanone suture). It says this was the blue internal suture which was visible to Mrs V on 17 April 2025. The Trust says this is a biodegradable suture material, which was designed to stay in the womb and not be removed.

14. The Trust also explain Mrs V’s c-section wound was covered with a PICO dressing, which creates suction and reduces risk of infection. It also says there are certain risk factors following a c-section which increase the risk of infection including diabetes, a BMI over 35, increased blood loss and having an emergency procedure. Mrs V had all of these risk factors.

The Trust left a blue internal suture in her abdomen following her C-section and she developed an infection

18. Mrs V tells us the Trust left a blue internal suture in her abdomen when closing up her C-section on 17 March 2025. She feels this caused her to develop an infection and be admitted into hospital to be treated.

19. We are sorry to hear Mrs V developed an infection and was admitted to hospital. We appreciate this was particularly distressing as she had to spend time away from her newborn son.

20. Mrs V tells us her midwife discovered the blue suture on 24 March 2025 when Mrs V’s PICO dressing was removed. She tells us on 27 March 2025 she started getting blistering on her abdomen which turned into an open wound the next day. The blue suture came through the open wound. Mrs V believes the blue suture being left in her caused the infection and opening of the wound.

21. The Trust explained in its response that following Mrs V’s C-section her rectus sheath (the tough fibrous part in the abdomen) was closed with a loop PDS (polydioxanone suture, a biodegradable suture material). It says this was the blue internal suture Mrs V saw. The Trust explains this type of suture is designed to remain inside the womb and not be removed. It was only visible because Mrs V’s wound had broken down.

22. We asked our adviser if the Trust perform the c-section in line with guidance in regards to the closing and dressing of the incision. They explained the Trust did correctly carry out the c-section when closing and dressing the incision. They also explain that PICO dressing (a type of single-use negative pressure wound therapy designed to remove excess fluid from wounds) is standard clinical practice for women who have factors which increase their chances of infection. Mrs V had diabetes, a high BMI and increased blood loss which NICE guidelines (HTG 509) and NICE guidelines 192 state are risk factors of infection.

23. NICE guidelines states there is evidence to support the use of PICO negative pressure wound dressings for closed surgical incision. PICO dressings are associated with fewer surgical site infections and seromas (a build-up of fluid under the skin) compared to standard wound dressings.

24. The above NICE guideline states that, although uncommon, there are known risks that some women do develop skin blisters and maceration with PICO dressings.

25. It is unfortunate that Mrs V developed an infection, which opened to expose the blue suture material inside. We understand this would have been very sore and distressing when she wanted to be home spending time with her newborn baby.

26. We can see the Trust acted in line with guidance by dressing Mrs V’s incision with a PICO dressing as this was the correct cause of action to reduce Mrs V’s chance of infection. We hope the work we have completed on her case provides her with an explanation for what happened.

27. We have seen no indication of maladministration and will not be taking this part of the complaint further.

Trust staff did not have a clear understanding on how to care and treat her wound on 28 March 2025.

28. Mrs V says when she was an inpatient on 28 March 2025, she did not feel Trust staff had a clear understanding on how to care and treat her wound. She says that the doctors and midwives were having conversations in front of her and she reports these conversations included disagreement about whether to dress her wound or leave it uncovered.

29. Mrs V says without the Tissue Viability Nurse (TVN – a nurse that specialises in wound care) staff did not know how to provide the right treatment and care. The Trust explained in its final response that TVN is not available at the weekends.

30. Mrs V says she lost faith in the staff treating her as the advice was so contradictory. She says she found it painful to sit up and breastfeed her son and was not given any support on how to do this whilst caring for her wound.

31. The Trust apologised for the poor communication around her care and acknowledge its communication at the time could have been better and would have reassured Mrs V she was receiving the appropriate care and treatment. Factually we note communications does not form part of the scope we are investigating.

32. We asked our adviser what should have happened in Mrs V’s care and treatment when she was admitted into hospital. From advice sought we understand it is common for TVN to only be available in the weekdays and in its absence, Trust staff took the right course of action. The staff started Mrs V on IV antibiotics, took swabs to be sent off and tested and made a referral to TVN.

33. Our adviser explains the doctors and midwives’ different plan of action on whether to dress her wound, would not have changed the outcome of needing TVN and antibiotics.

1. We have carefully considered Mrs V’s complaint about the Trust. We are sorry to hear Mrs V developed an infection following her caesarean and had to be admitted to hospital. From what she has told us, this was a distressing time and made her feel she was unable to bond with her newborn son.

2. Based on the evidence we have considered, we have seen no indications that anything went wrong in the Trust’s care and treatment of Mrs V during the closure of her caesarean on in March 2025. We have also seen no indication the Trust did anything wrong in its care and treatment of Mrs V’s wound during her hospital admission in March 2025.

4.We recognise how important this complaint is to Mrs V, and we would like to take this opportunity to thank her for bringing her complaint to our attention. We hope our explanations below show how we have considered this complaint and provides reassurances that the Trust followed relevant guidelines.