United Lincolnshire Teaching Hospitals NHS Trust

5. Mr Z complains about aspects of care and treatment he received United Lincolnshire Teaching Hospitals NHS Trust (the Trust) in June 2024. He attended the Trust’s emergency department (ED) in mid June 2024 due to an agricultural injury on his foot and complains the Trust failed to:

• review and treat a fractured toe • flush the wound • admit him to surgically debride the wound (remove damaged tissue or foreign objects) • provide him with antibiotics.

6. Mr Z says the failure to appropriately treat the wounds and to prescribe antibiotics led to an infection requiring surgical debridement and this left a permanent scar on his right foot. He also says the experience caused him to lose trust in the hospital.

7. It led to some poor mental health due to time spent off work and he missed an opportunity to work at the Paris Olympics. Mr Z also says the trust had made his recovery at least two weeks longer which was an extra two weeks off work. He told us he had to go through an attendance hearing at work because of the time off from this incident.

8. Mr Z is seeking an acknowledgement of the failings, service improvements, and a financial remedy.

9. Mr Z attended the emergency department (ED) at the Trust on 5:02pm due to an injury on his right foot sustained in a farm machinery accident in the middle of June 2024.

10. On arrival, the consultant reviewed photographs of the wound, and a treatment plan was initiated. This included cleaning, suturing, a foot X-ray, and a tetanus injection (to prevent a serious bacterial infection).

11. During the wound care process, grass was removed from the wound using medical tweezers and was then cleaned with saline-soaked sterile gauze. It was initially considered there was no evidence of active bleeding, neurovascular (nerve or blood flow) injury or ligament damage.

12. The consultant confirmed this by the absence of changes in skin colour, normal movement of the foot and toes, preserved sensation. This indicated there was no damage to the nerves or blood vessels.

13. Mr Z’s tissue viability (health and integrity of the body tissues) was also assessed.

14. Local anaesthesia (medication which temporarily numbs a specific area of the body to prevent pain during minor procedures) was injected to numb the area for suturing. The wound was closed with 12 stitches and dressing.

15. An X-ray of his foot was completed at 6.29pm, and a report was completed by the radiographer around 6.53pm. The report identified the margin of the bone on the second metatarsal (bones of the forefoot) appeared slightly different to the other metatarsals.

16. At the time of assessment by the ED doctor, it was considered the X-ray showed no evidence of bone injury.

17. Mr Z was discharged from hospital.

18. Three days later, Mr Z noted a foul smell, redness, and discharge. An email consultation took place with his GP who prescribed antibiotics and requested he attended the urgent treatment centre (UTC).

19. A day later, he attended the UTC at the hospital. On examination in the UTC, a wound swab was taken for analysis.

20. The swab results indicated there was ‘mixed enteric flora’ (multiple bacterial species in the gastrointestinal tract).

21. Mr Z attended an appointment at the fracture clinic five days later at 3:30pm.

22. He was seen the same day by the orthopaedics department.

23. On examination of his right foot, it was identified there was an 8cm wound over the dorsal aspect of the right forefoot with necrosis (death of cells in body tissues) and slough (non-viable tissue which accumulates on the wound bed). There was also some discharge from the wound.

Fractured Toe

27. Mr Z says the Trust failed to review the X-rays along with the review by the radiology team. He says following the Trust’s explanation of what happened, there is still confusion over what the outcome of the two assessments were. Mr Z says the radiologist said there was a fracture and the consultants said there was not a fracture.

28. The Trust’s response of 6 September 2024 explained the report was completed by radiographer which confirmed ‘cortical irregularity at the head of the second MT suggestive of fracture at this level. No other convincing adverse acute radiographic features identified’.

29. The Trust said this means the margin of the bone on the second metatarsal; (bones of the forefoot) appears slightly different. It explained the ED consultant and orthopaedic team had reviewed the X-ray images and were unable to identify any suspicion of a fracture.

30. In its second response of 19 November, the Trust apologised for the confusion with staff identifying a possible fracture. Mr Z’s case was reviewed by an ED consultant and an orthopaedic consultant who were still unable to identify a fracture. The radiology team were contacted who confirmed following a further review and second opinion, the information in the initial X-ray report was correct.

31. At Mr Z’s first attendance in mid-June, the attending clinician documented a foot X-ray was requested at 6:12pm but did not document if it was reviewed. The same clinician has clarified in his personal statement he had reviewed the X-rays and found no bone injury.

32. General Medical Council in ‘Good medical practice’, which says in providing clinical care, the practitioner must ‘promptly provide (or arrange) suitable advice, investigation or treatment where necessary’.

33. Our adviser says the actions of the clinician were in line with the above guidance, and appropriate as the clinician requesting investigations reviews the images. The X-ray was reviewed as per standard practice, and no injury was identified.

34. The X-ray report noted a cortical irregularity (abnormal changes in the outer layer bone tissue) suggestive of a fracture and advised clinical corelation. Clinical correlation refers to the practice of matching diagnostic results, in this case an X-ray with Mr Z’s symptoms, medical history and physical examination findings.

35. The actions of the practitioners are in line with GMC guidelines on ‘Good medical practice’ which require them to ‘consult colleagues or seek advice from your supervising clinician, where appropriate’.

36. The clinical correlation was provided by an ED and orthopaedic consultant who did not identify a fracture on the Trust’s response.

37. The Royal College of Emergency Medicine (RCEM) in ‘Management of Investigation Results in the Emergency Department’ guidance states ‘all reports of abnormal radiological investigations requested by the Emergency Department team must be reviewed by a clinician, taking the clinical scenario into account, and necessary actions that may be required.’

38. Our adviser states the X-ray did not suggest of any other acute radiographic feature. The ED consultant and orthopaedic review was appropriate and in line with above guidance as on clinical correlation they did not feel there was a fracture.

39. As such, the initial practice was appropriate as Mr Z had an X-ray and the images were reviewed by the clinician as mentioned above.

40. While the clinician’s statement suggests the report was not reviewed on the day of Mr Z’s fist attendance, the records show Mr Z was assessed at 6:12pm, the foot X-ray was reported at 6:53pm, and the clinician entered notes at 7.50pm. This shows they had an opportunity to review the X-ray report.

41. Our adviser also adds given the nature of the injury (crush injury associated with a contaminated wound), the line of treatment would be different if the fracture was obvious or identified at the time of assessment, as then Mr Z would be managed on the lines of having an open fracture. This was not applicable in Mr Z’s case.

42. We recognise it was frustrating for Mr Z to receive conflicting information especially when it related to his care and treatment at a difficult time. The evidence shows Mr Z did not have a fracture and the X-rays were reviewed appropriately.

Flushing of wound

43. Mr Z felt the wound should have been flushed prior to stitching. He said one or two pads dampened with saline solution and were placed on the wound. He said at no time was it flushed. The area around the wound was cleaned prior to the local anaesthesia being injected.

44. He also said if a saline flush of the wound was completed, why was this not recorded in the patients notes with the other details.

45. Mr Z said the method used to flush his wound did not provide a steady flow of solution across the wound, and the removal of pathogens was unlikely, which was later confirmed by the UTC swab results. He referred to the National Institute of Care and Excellence (NICE) definition of a wound flush, and said a thorough wash out was not achieved as the doctor failed to carry this out appropriately.

46. The Trust said this type of wound should be managed by stopping the bleeding initially and then cleaning the wound before removing foreign objects and stitching the wound to ensure it is closed.

47. It confirmed the wound was cleaned and then closed with no further issues or active bleeding. The response said during the cleaning process, saline was used to flush the wound and then the remaining debris was manually removed.

48. In its further response, the Trust explained the wound was flushed with saline-soaked sterile gauze to ensure all foreign material was removed prior to suturing.

49. It said it was unclear why the responsible doctor did not clearly document saline was used to flush the wound and apologised for the lack of documentation. It said the doctor had taken the complaint seriously and identified areas that require them to personally improve upon for future practice.

50. We considered whether the records indicate Mr Z received appropriate wound care and treatment.

51. Having reviewed the images of the injury provided by Mr Z, our adviser says he did not receive the appropriate wound care.

52. NICE Clinical Knowledge Summaries (CKS) in ‘Lacerations: Scenario: Management’ states if the laceration is infection or at high risk of infection would require appropriate cleaning and management. It explains in detail stating:

• ‘Disinfect the surrounding skin with an antiseptic. Avoid getting antiseptic into the wound.

• Keep hair out of the wound. If necessary, clip the hair around the wound with scissors (rather than shaving). Apply simple ointment to flatten any remaining hair away from the wound.

• Debride devitalized tissue and pick out as much foreign material as possible.

• When debriding or exploring the wound, anaesthetize the area. The pain associated with the injection can be reduced by:

• Using a 25–gauge needle.

• Warming the anaesthetic to body temperature before use.

• Injecting through the cut edge of the wound (rather than through a new puncture).

• Infusing the anaesthetic slowly.

• Using a topical anaesthetic (such as EMLA cream) before infiltration with a local anaesthetic.

• Irrigate the wound with potable water, cooled boiled water, or normal saline.

• For lacerations that are visibly contaminated, irrigate at high pressure with a syringe and a green needle to remove visible debris from the wound.’

53. Our adviser says the mechanism of Mr Z’s injury, exposure to external components, and the nature of the wound shows it was a complex wound at a high risk of infection.

54. RCEM learning in ‘Surgical Management of Acute Wounds in the ED’ defines a complex wound as one which is ‘associated with significant tissue loss or devitalization; communicates with viscera (e.g. fistula), body cavities (e.g. laparostomy), joints or prosthesis; or has associated injuries or paths leading to vital structures’.

55. NICE CKS on ‘Lacerations: Scenario: Management’ also says, ‘for infected wounds or wounds with a high risk of infection, the wound should be cleaned and dressed and then observed for 2–5 days to ensure no infection is apparent before it is closed (delayed primary closure).’

56. According to the Trust’s response, Mr Z’s wound was closed on the same day. As our adviser states the nature of Mr Z’s wound was a complex wound at a high risk of infection, and treatment of his wound was not in line with the above guidance.

57. As such, the Trust did not provide the appropriate wound care and treatment in line with NICE CKS ‘Lacerations: Scenario: Management’. This falls short of what we would expect from an organisation. We will consider the impact of this failing later in our report.

58. We also looked at the Trust’s response in terms of how Mr Z’s wound was managed. The response acknowledges treatment to prevent infection is to correctly debride and clean the wound. The Trust complaint response and the clinician’s statement appear contradictory as one suggests the wound was ‘flushed’ and other suggests cleaning with soaked gauze swab. Mr Z has also mentioned the latter in his complaint.

59. ‘Good medical practice’ which says, ‘You must make sure that formal records of your work (including patients’ records) are clear, accurate, contemporaneous and legible’.

60.  Our adviser comments the Trust should follow the above guidelines is to keep up to date with guidelines relevant to practice, appropriate reflection and documentation of notes.

61. The discrepancies between the Trust’s response and the clinician’s statement raise concerns regarding the accuracy, and reliability of the records provided. Where conflicting accounts exist, this undermines the confidence of the records. As such, it is advisable to the Trust to ensure accurate record keeping is maintained.

Debridement

62. Mr Z said the correct course of action would have been an orthopaedic consultation leading to surgical debridement in theatre. He said the debridement was completed on towards the end June, which is 12 days after he attended the ED. He also said as this did not take place in mid June, the need for appropriate wound care prior to his discharge from ED was important to prevent infection.

63. Given the contamination with soil and faeces was highly likely and involved agricultural machinery, Mr Z had to walk barefoot over two hundred metres through cut grass in a field which was home to livestock. He said this information was passed to the medical professionals and the notes state ‘FB [Foreign Bodies] all removed’.

64. Mr Z said the finding and removal of foreign bodies (grass) would suggest a strong likelihood that unseen pathogens were also present.

65. Mr Z said there was a failure by the ED team to involve the orthopaedic team to arrange the required debridement and cleaning of the wound in theatre.

66. The Trust says in its response once the stitching was complete, Mr Z was able to move his toes, and the skin was of normal colour. It said the plan upon discharging from ED was for Mr Z to follow up with his GP for a wound review, and a change of dressing two days later. He was also advised if he experienced any pain worsening, change of colour to the skin or feeling generally unwell to seek medical attention.

67. We considered whether the Trust should have involved a speciality to manage Mr Z’s wound.

68. The evidence shows there was no speciality input on Mr Z’s first attendance. Mr Z contacted his GP who prescribed antibiotics. As his GP did not offer a wound care service, Mr Z was directed to attend an UTC. He attended the day after his first visit to the ED.

69. Following his attendance at the UTC, he was seen by an orthopaedic specialist at the fracture clinic towards the end of June and was admitted into hospital. The surgical debridement took place three days later.

70. Our adviser says Mr Z had factors associated with a higher risk of wound infection in the form of a crush injury, complex laceration, contamination with foreign body and environmental factors. As such, he required appropriate management, review and follow up.

71. NICE CKS on ‘Lacerations: How should I assess a person with a laceration’ states ‘A laceration is at high risk of infection if it is contaminated with soil, faeces, body fluids, or pus. Other risk factors for infection include… ‘a wound length of more than 5cm’.

72. In Mr Z’s case, the evidence shows his wound was contaminated and around 8cm.

73. The British Orthopaedic Foot and Ankle Society (BOFAS) in ‘Crushed Foot’ states the goals of early management include reducing ischemia and tissue necrosis… and preventing infection’. It further advises ‘early referral to a trauma centre’.

74. This is also supported by the RCEM learning in ‘Surgical Management of Acute Wounds in the ED’ which states ‘while clean-contaminated wounds can be closed by primary intention, contaminated and dirty wounds will be referred to the appropriate speciality for irrigation, debridement and formal closure in theatre.’

75. Our adviser states Mr Z should have received input from a speciality team in line with the above guidance. As such, we consider there is a failing here and we will consider the impact of this in detail later in our report.

76. We recognise how challenging this experience has been for Mr Z and understand how distressing it was for him to obtain further advice from his GP to assist him with his symptoms when he felt he should have received optimal care while he was in the ED.

Antibiotics

77. Mr Z says there was a failure by the ED staff to correctly assess the risk of infection, conduct the correct wound care, and assess the precautionary need for antibiotics to mitigate the high infection risk. He says had he not contacted his GP, and antibiotics were not prescribed, there would have been a greater risk of infection or sepsis with the potential for life changing consequences.

78. Mr Z goes on to state the swab result was analysed during his appointment towards the end of June, and ‘mixed enteric flora’ was found. He says this result proves pathogens were present, and antibiotics would have been appropriate. He says the presence of pathogens, and later the infection contributed to the necrosis.

79. The Trust explains in its complaint response, the responsible ED doctor advised it is not routine practice for a prescription of antibiotics to be given after suturing. It also explains antibiotics should only be prescribed when necessary and considering of patient’s medical history, age, type of contamination and any visual signs of infections.

80. The Trust goes on to say the ED doctor felt his examination of Mr Z’s injury and wound care was sufficient, and his advice was to schedule a follow-up appointment with the GP to monitor the wound. The responsibility would be on the GP to prescribe antibiotics if there were any signs of infection.

81. Our adviser says Mr Z was at a high risk of developing a wound infection due to the mechanism of injury, potential contamination, size and shape of the wound. This is noted in paragraph 69 in detail.

82. According to NICE CKS on ‘Lacerations: Scenario: Management’, wounds like Mr Z’s at high risk of infection, they should be considered for prophylactic antibiotics with a review arranged to assess the wound for signs of infection if not started on antibiotics already.

83. Prophylactic antibiotics are used to decrease the risk of developing infections.

84. In its response, the Trust also refers to NICE guidelines as above for laceration management which say if a laceration is at high risk of infection, the wound should be appropriately cleaned and consideration for antibiotics and/or tetanus injection should be actioned.

85. The divisional clinical director commented there is little evidence to support the requirement of antibiotics to prevent infections for wound. The correct treatment to prevent the infection is to correctly debride and clean the wound.

86. Our adviser says Mr Z did not receive appropriate care by the Trust’s own admission.

87. In the medical records, it is recorded at 7.50pm Mr Z was advised ‘to contact GP for wound review… advised to seek medical attention if worsening of pain, change of colour, fever or feeling unwell. Advised to take simple pain killers [at] home’.

88. The records also show Mr Z commenced on antibiotics treatment following his GP appointment. This was three days after his attendance at the ED.

89. While the ED doctor safety netted Mr Z, advising him to contact the GP and taking simple pain killers was not sufficient considering the nature of his wound.

90. Our adviser states the risk of the wound to develop an infection was not assessed appropriately in line with NICE CKS on ‘Lacerations: Scenario: Management’. He also adds he should have been commenced on antibiotics. As such, this is a failing.

91. We will consider the impact of this failing below.

Impact

Wound care

92. In terms of wound care, our adviser comments Mr Z attended the ED with a complex and potentially contaminated wound. Our adviser says the care and treatment provided was insufficient to manage the wound.

93. On the balance of probabilities, our adviser says the wound had a high risk of necrosis (breakdown) due to its site and possible devitalisation (lack of / reduced blood supply) and complexity mentioned above.

94. Our adviser says this may on the balance of probability have had an impact on Mr Z’s wound healing. We consider this outcome may have been avoidable with earlier intervention with the correct wound care.

95. We recognise Mr Z says he lost trust in the hospital after receiving the initial treatment. This was distressing, and we consider this led to his frustration and reduced confidence in the care he received.

Debridement

96. We know from the evidence, Mr Z had surgical intervention 12 days after his initial injury and had no input from a specialist to review his wound.

97. The failing to involve the appropriate speciality at the initial presentation likely delayed full specialist assessment and management of Mr Z’s complex and contaminated foot injury.

98. We consider surgical debridement may still have been required considering Mr Z’s injury, and a scar may have likely occurred following his surgery.

99. What we can say is earlier specialist involvement may have reduced the progression of Mr Z’s injury and potentially limited the overall duration and complexity of his recovery.

100. We also know this failing contributed to Mr Z having to seek further care via his GP and an UTC before eventual surgical review.

101. The need to access care through multiple healthcare settings days after his injury before receiving definitive specialist review may reasonably have contributed to Mr Z’s feeling of uncertainty and loss of confidence. We recognise this would have been frustrating, particularly when dealing with a painful and functionally limiting foot injury.

Antibiotics

102. The delay in receiving antibiotic treatment for a contaminated high-risk wound likely increased Mr Z’s infection progressing before appropriate treatment was initiated at a different hospital. While infection can still occur, earlier treatment may have reduced the duration of his infection, and Mr Z having to seek further treatment from his GP which could have started in the ED.

103. We recognise the progression of Mr Z’s symptoms and the need to seek care from his GP, and the UTC before definitive hospital management at a different hospital caused him distress and loss of trust in the services he received.

104. We also understand the injury and the subsequent recovery understandably caused significant distress, and disappointment for Mr Z, particularly in relation to time off work, and the loss of work opportunities.

105. Our adviser states these wounds can take time to heal, even with appropriate therapy.

106. As such, given the nature of Mr Z’s injury, a period of reduced function and recovery time would likely have occurred even with initial management. While we recognise this impacted Mr Z, these broader consequences cannot be directly linked to the failings found, as they were likely a factor resulting from the injury itself.

1. We have identified potential failings for the following:

• suboptimal wound care • lack of specialist intervention • failure to initiate antibiotic treatment

2. We found the suboptimal wound care likely impaired Mr Z’s wound healing. We also consider the lack of early specialist intervention likely delayed definitive management and the failure to initiate antibiotic treatment likely allowed Mr Z’s infection to progress, prolonging his recovery.

3. We will partly uphold the complaint overall.

4. We have made recommendations based on the identified failings.