Nottingham University Hospitals NHS Trust

3. Miss B complains about the care and treatment the Trust provided to her father, Mr B between January to May 2024. Specifically, she has concerns the Trust: • did not treat her father’s infections appropriately • did not provide adequate nutritional support • did not manage her father’s skin properly • mismanaged a crack in her father’s skull.

4. Miss B says the Trust’s poor care contributed to her father’s deterioration and death. She says this was avoidable. This has caused distress and suffering.

5. Miss B would like the Trust to provide service improvements and provide a financial remedy.

6. We recognise Mr B had a lengthy hospital admission. We have intentionally left the below background brief as we will go into this in detail in our explanation of the complaint.

7. Mr B presented to the Trust on 12 January 2024, with complaints of shivering, lethargy, and discharge from his left diabetic foot ulcer. He was admitted and treated for sepsis. He was admitted to the high dependency unit (HDU). He improved and was discharged on 19 January.

8. Mr B was admitted to the Trust again due to self-inflicted lacerations on 26 February. He remained in hospital. He continued to deteriorate and it was decided in May he was for end-of-life comfort care.

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 below.

Crack in skull 13. Miss B has concerns her father sustained a crack to his skull whilst a patient on HDU in January 2024. The Trust has no injury recorded for his stay in HDU. It says a change of position whilst her father was in cardiac arrest may have resulted in bruising to the head.

14. We recognise at the start of Mr B’s second admission it was queried if he had a fracture to his head. This was because a computed tomography (CT) scan had been carried out to see if Mr B had suffered a stroke, as he had varying levels of consciousness at the time. A CT scan is a scan that takes images of inside the body.

15. The scan incidentally showed an area of gas in the head. This caused the radiologist query whether there was any trauma, or presence of infection. When an abnormality is seen, it is generally queried if an area shows changes as a result of trauma, infection, or a tumour.

16. The Trust acted on this and arranged a follow up magnetic resonance imaging (MRI) scan. This is a more detailed scan which produces higher quality images to a CT scan. This scan ruled out evidence of any bruising to the skull, or evidence of a fracture.

17. Our radiology adviser has carefully considered this, alongside the radiology imaging. The RCP and reporting guidance is applicable here, alongside the NICE head injury guidance. It sets out guidance for reporting on a CT of the head and brain and gives guidance on the general structure of the report and turnaround times.

18. Our radiology adviser explains the CT scan taken on 21 February found Mr B did not have a haemorrhage or lesion. The report shows an area of gas, but no fracture was seen within the skull base and facial bones. This means there was an abnormal finding on the CT scan, and it was appropriate to query if there was any infection or trauma.

19. Our radiology adviser explains this was an appropriate interpretation of the imaging. As a result, it was appropriate to take steps to rule out a head injury or trauma and arrange follow up treatment. Mr B was treated with precautionary antibiotics, in case the changes were showing due to an infection.

20. The MRI scan of the head was carried out on 28 February to investigate this further. The scan showed there was no mass or lesion, no abnormality and no evidence of trauma.

21. Our radiology adviser explains the MRI scan shows there were no worrying features present. As an MRI scan produces more detailed images, this supports there is no evidence suggest any injury to the head.

22. Our radiology adviser explains each of the scans were reported and acted on in line with the above guidance. We hope this provides Miss B with reassurance about the scans and findings.

Management of infections 23. Miss B has concerns her father’s repeated infections were not managed appropriately and the Trust did not take the correct steps to get them under control. The Trust says Mr B developed an infection in the trans-metatarsal amputation site which was managed appropriately. Our podiatry adviser has considered this carefully.

24. The diabetic foot guidance is applicable here. It covers preventing and managing foot problems and sets out antibiotic prescribing for diabetic foot infections. The guidance explains if a diabetic foot ulcer is suspected and a wound is present to send a soft tissue sample or bone sample for microbiological examination, or a deep swab if this cannot be obtained. It says to consider an X-ray to determine the extent of the problem, and to think about osteomyelitis (an infection in the bone).

25. The guidance says antibiotic treatment for people with suspected diabetic foot infection should be started as soon as possible. When choosing an antibiotic, several factors should be taken into account such as the severity of the infection, the risk of complications, previous microbiological results and previous antibiotic use.

26. Our podiatry adviser explains Mr B presented on 12 January with a severe infection from his foot. He was noted to be critically unwell and had a range of comorbidities. He was treated for sepsis, secondary to an infected foot ulcer, initially with intravenous Tazocin and fluids. Tazocin is an antibiotic used to treat severe broad-spectrum infections.

27. The Trust liaised with the intensive care and microbiology teams for advice, and arranged for Mr B to have blood cultures, wound swabs and a foot X-ray, to check for osteomyelitis. He was then started on intravenous (IV) meropenem, which is appropriate management. Meropenem is another antibiotic, used to treat severe infections, including skin infections and septic shock. He was also given a second antibiotic, co-amoxiclav, due to his updated microbiology results, which is also recommended in line with guidance.

28. On 14 January, Mr B requested a DNAR discussion. The record of the discussion shows he explained he did not wish to have resuscitation in the event of a cardiac arrest. He said this was not a decision he had made on a whim and had been thinking about for three years. He said he had lived a full life and was fed up of the foot infections. He acknowledged his infections were being treated at that time, but asked his wishes were respected. He was deemed to have capacity and was orientated to time, place and person. He continued to receive full active treatment with antibiotics.

29. On 15 January, Mr B was reviewed by the diabetic foot team. A plan was made to wait for his X-ray results, and continue of co-amoxiclav for the soft tissue infection.

30. Mr B was noted to have improved significantly. He was discharged on 19 January as a result, with outpatient follow up in place with the diabetes team on 22 January. This management was appropriate and in line with the above guidance.

31. Mr B was seen in the community on 2 February in the diabetic foot clinic for a planned review. He explained he had not been feeling well, and he had an ulcer which had deteriorated.

32. Diabetes can cause fat deposits to build up in arteries which can clog them, so that not enough blood flow gets to the feet. Diabetes can cause damage to nerves in the legs (neuropathy) via a number of pathways. Mr B had no sensation to his feet due to this. He was referred back to the Trust for surgical input. An X-ray was arranged which showed signs of osteomyelitis.

33. The Trust arranged a duplex scan, a scan to measure the blood flow, and it was explained to Mr B d depending on the results he may need an amputation of his big toe, big toe and metatarsal, or all toes and metatarsals (trans metatarsal). Metatarsals are bones in the foot.

34. On 9 February, Mr B had an angioplasty to try to improve the blood flow to his foot. An angioplasty is a procedure used to widen narrowed or blocked arteries to restore blood flow. Samples taken in theatre grew bacteria and he was treated with co-amoxiclav as a result. The Trust explained based on the results, Mr B would benefit from an amputation at this point to remove the source of infection.

35. On 12 February he underwent a trans-metatarsal amputation. This is a surgical procedure to remove part of the foot and with it any deep infection, usually caused by diabetes and poor blood flow to the foot. Post surgery he was treated with antibiotics. The Trust considered the microbiology and provided appropriate antibiotic treatment in line with the diabetic foot guidance.

36. On 15 February Mr B refused further antibiotics and said he did not want to be treated. The doctor explained he had an infection, and the iv Tazocin was being given to treat this. The doctor advised without this it is likely he would deteriorate. Mr B said he did not want further treatment or pain relief, and this was refused.

37. The Trust discussed Mr B’s decision with the microbiology team for advice. Microbiology advised if Mr B did not accept the antibiotics he could die. The doctor explained he would speak to Mr B again to reiterate its advice for antibiotics. Mr B said he wanted to stop all treatment and said he had thought about this for weeks, he said he understood the outcome of this, and it was his choice. Mr B self-discharged home against medical advice on 25 February.

38. On 26 February, Mr B was taken to the Trust again by ambulance after self-inflicted lacerations. He was referred to the plastics team and psychiatry team and admitted. He was treated with intravenous antibiotics due to the lacerations and started to refuse to eat and drink. The Trust was providing full active treatment in attempt to treat Mr B’s infections. Mr B was receiving metronidazole and co-trimoxazole, antibiotics used to treat bacterial infections.

39. During this admission, Mr B expressed he did not wish to receive medications. There was regular input from the psychiatric team, and he was deemed to have capacity to refuse treatment on 13 March. It is documented he was able to explain events, his medical issues, illness and complications and understood the consequences of refusing antibiotics and that it was likely he would deteriorate. The Trust stressed he needed this medication, but that it could not force him as he was deemed to have capacity. He remained refusing all fluids and treatment.

40. On 5 April Mr B explained he did not want treatment and understood he would keep getting infections. He refused all medical interventions. Mr B was progressing and becoming more unwell, appearing to have a urinary tract infection, which is common in patients which are dehydrated. His C-reactive protein (CRP) went above 200 (a normal level is five or below). CRP is a blood test that measures inflammation levels in a body, these raised levels indicated infection.

41. The Trust felt at this point Mr B’s mental health had deteriorated to the point where his capacity was affected to make decisions. It decided to treat him in his best interest, against his wishes, using the legal framework called ‘deprivation of liberty safeguards’ (DOLS). This ensures care is in the person's best interest, legally authorised, and subjected to independent assessment and regular review.

42. The Trust attempted to cannulate Mr B so it could treat him and needed multiple members of staff to assist to restrain him. He was refusing and told staff he would pull this out straight away. This had to be abandoned as it was deemed to be unsafe. Staff advised Mr B they would have to cannulate against his wishes and would call security to assist. He was able to be cannulated with the help of four members of staff. As a result, the Trust were able to provide fluids and antibiotics.

43. Our podiatry adviser explains this was a really difficult situation as Mr B was becoming refusing all intervention and explaining he did not want to continue. The records suggest the Trust was doing what it could in attempt to treat Mr B’s infection in the clinical circumstances. We understand this was a really complicated situation and must have been very difficult for the family.

44. The Trust continued to treat Mr B in line with his best wishes against his requests, inserting cannulas and a tube for feeding. This required four members of staff. The records explain a family discussion took place on 17 April, where it was expressed Mr B’s comfort was a priority. A multidisciplinary team (MDT) meeting took place, and it was accepted he was not improving and medications could be stopped, in line with these wishes. He was then placed on end-of-life comfort care.

45. We recognise what an incredibly complex and distressing experience this must have been. The Trust was taking the appropriate steps to try to treat Mr B’s infections, in line with guidance. It carefully considered Mr B’s test results, reacted to any change in microbiology, switching antibiotics and tailoring the treatment to specific bacteria.

46. As Mr B was under so many medical teams at once, and experiencing issues under different teams, it is possible things could have been better explained to the family. It may have been useful to explain about the different infections Mr B was experiencing to help them understand what was happening at each point. We hope our explanations about what was happening has been useful to the family to explain the Trust were acting in line with guidance.

Management of nutrition 47. Miss B has concerns her father’s weight loss and nutrition was not managed appropriately. He went into hospital in February, and a tube for feeding was not inserted until April. She says there were opportunities for there to be earlier interventions regarding feeding.

48. The Trust says Mr B was referred to the dietetic team on 29 February and continued to be monitored throughout his stay. He was prescribed supplements and food charts.The Trust says Mr B was clear he did not want a tube inserted and had capacity to understand the implications. On 15 April it was inserted in his best interests rather than with consent.

49. The nutrition guidance is applicable here. Our nursing adviser has carefully considered the evidence and information. The guidance sets out patients should be screened on admission using a validated tool and acted upon, and then weekly.

50. The ‘MUST calculator’ is a well-established tool used to determine a patient’s nutritional risk. A score of zero is low risk and requires routine clinical care, with weekly screening. A score of one is medium risk and a patient’s dietary intake should be documented with a care plan in place. A score of two or more is high risk, and a patient should be referred to a dietician for a considered care plan.

51. On admission, it was highlighted Mr B’s ‘MUST’ score was high, and he was promptly referred to the dietician as a result. He was reviewed by the dietician on 29 February, three days after his admission, in line with MUST guidance.

52. The dietician continued to regularly review Mr B and had very frequent input, even on the days where Mr B was refusing support. The dietician prescribed supplements, snacks and regularly encouraged Mr B to eat and drink.

53. Mr B explained he was experiencing swallowing difficulty, and nausea, this was documented on 1 March and investigated. He was reviewed for a throat assessment. On 4 March, the speech and language therapy team (SALT) explained it could not find any evidence of oral thrush or any swallowing difficulty. At this point, Mr B started to refuse food and interventions. He was referred to the ear nose and throat team (ENT) and the gastrointestinal team to review his throat and vomiting.

54. He was reviewed again by the SALT team on 6 March and refused to engage. The dietician reviewed Mr B and he explained he did not want to eat, with food charts showing Mr B was declining most meals. The dietician felt his intake was impacted by his mood, and due to his mental health concerns, he was not an appropriate candidate for enteral or artificial feeding. This is due to the risk of pulling out the tubes. It was encouraged he continue with snacks and supplements.

55. At a dietician review on 12 March no choking or aspiration was observed and Mr B continued to refuse to eat. He was deemed to have capacity at this time when refusing food, fluids and antibiotics. The dietician explained on 25 March due to Mr B continuing to refuse food and medication, and having capacity, the team were only able to have limited input.

56. On 5 April, Mr B appears to have deteriorated further, and it was felt his capacity was potentially impacted to make decisions in his best interests. He was found to not have capacity, and the Trust made the decision to treat him against his wishes, in his best interests. On 8 April the dietician reiterated the teams input was extremely limited without further intervention such as a feeding tube, but there were risks in considering this as it was felt likely Mr B would pull this out, which could put him at risk of harm.

57. We recognise Miss B questions if her father could have been fed via a tube sooner. As Mr B had capacity, this could not have been done sooner. This is a legal process based on a person’s capacity and he was deemed able to make decisions at that time.

58. On 10 April, the Trust attempted to insert a tube for feeding due to Mr B’s refusal to eat. The records explain four members for staff were needed and the tube was inserted. The Trust continued treat Mr B against his wishes.

59. On 17 April, it was felt despite continuing to treat Mr B, his physical condition as not improving. The records explain the family expressed a wish Mr B’s comfort and wishes should be his priority. As a result, the tube was removed and comfort care was started.

60. After careful consideration of all the evidence, our nursing adviser explains Mr B was appropriately reviewed and referred to the appropriate teams for input and support regarding his nutrition throughout the admission.

61. His risk was continuously monitored, he had strict food charts and supplements prescribed and in place. He was weighed weekly and frequently encouraged to eat and drink. Mr B was clear he did not want a tube or artificial feeding. Our nursing adviser says the records evidence the Trust doing what they could to get Mr B to eat and drink. This management was in line with the NICE guidance.

62. We are mindful this must have been a really difficult time and hope our explanations can offer some reassurance about the steps that were being taken throughout the admission.

Management of skin 63. Miss B says her father’s pressure sores were not treated properly and left to deteriorate. The Trust carried out an investigation into the deterioration of Mr B’s skin. This found he was not always repositioned as he declined interventions. The Trust acknowledged the non-concordance process was not followed and there were missed opportunities to upgrade Mr B’s mattress.

64. The pressure ulcer guidance is applicable here and sets out the interventions that should be carried out. Our nursing adviser has carefully considered how the Trust managed Mr B’s skin and wounds during the admission. We recognise the management for Mr B’s skin was not in line with guidance, and the Trust has accepted this.

65. The guidance explains a ‘braden assessment’ should be completed on admission. This is a widely used evidence-based tool for assessing a patient’s risk of developing pressure injuries or ulcers. There was a three-day delay completing this. This meant Mr B did not have the correct mattress in place, which took 12 days to be upgraded. Timely skin care and management was very important, particularly as Mr B had undergone an amputation.

66. Mr B was high risk and should have been turned every four hours. The records suggest skin checks were sometimes incomplete, and his repositioning was not always timely or effective as the guidance recommends.

67. We recognise some of these issues appear to be due to non-concordance, and there are entries to explain Mr B did not want to be repositioned or get out of bed. This aside there were delays and incomplete information recorded. There is an indication something went wrong here.

68. Our nursing adviser has carefully considered the impact of this and recognises it is possible this contributed to some skin damage or pressure areas for Mr B. We recognise this could have caused him some discomfort. Our nursing adviser explains this did not have an effect on his foot wound, and there is no evidence to suggest this was linked to his infection, deterioration or death.

69. Based on the above, we have considered the steps the Trust has taken to recognise the issues with Mr B’s skin management and discomfort. We understand the Trust has acknowledged this, apologised for it and completed a skin investigation.

70. Our nursing adviser has considered the Trust’s investigation. They explain the investigation and action plan are thorough and detailed. The Trust’s investigation acknowledged Mr B was not always repositioned as he should have been, and this was sometimes due to non-concordance. It explained Mr B had capacity and was within his rights to refuse, but in this case staff should have also followed the non-concordance process. It recognised there were missed opportunities to upgrade the mattress and the delay in the braden assessment.

71. The investigation set out it has shared learning from the incident and increased training. It has also increased the stock of mattresses, so they are now available on site. It apologised to Mr B for this and acknowledged where it got things wrong.

72. Based on this, it is evidenced the Trust has taken steps to recognise where it got things wrong and taken the appropriate steps to put this right. As a result, we do not think we need to investigate further.

73. We thank Miss B for taking the time to talk to us about her experience and her father and hope we have clearly explained the reasons for our decision.

1. We have carefully considered Miss B’s complaint about care her father, Mr B, received from the Trust. We extend our condolences to Miss B. We understand how important her complaint is to her.

2. After careful consideration, we think the Trust acted in line with guidance in managing her father’s care and treatment throughout this period. We understand Miss B has serious concerns about this, so we hope our explanation is helpful.