Northern Care Alliance NHS Foundation Trust

5. Miss R complains about the district nursing care the Trust provided to her sister, Miss O in September 2023. Specifically, Miss R complains: • it failed to monitor the ulcers on Miss O’s feet and leg and did not detect signs of infection.

• it did not accurately document each home visit on the medical records.

6. Miss O has died and Miss R believes failings in her care caused, or at least contributed to, her death. Miss R is concerned her sister’s district nursing medical records do not accurately reflect the condition of her ulcers. The family are devastated by her death, and this complaint continues to cause them distress and compound their grief.

7. As an outcome to this complaint Miss R is seeking financial compensation and service improvements.

8. Miss O was in her sixties at the time of the events. She was under the care of the Trust’s district nursing team, where it arranged home visits to treat and dress the wounds on her feet and lower leg. She had a complex medical history including vascular disease which caused the ulcers on her feet.

9. She also had a history of systemic lupus erythematosus (SLE) a chronic autoimmune disease that can affect multiple organs and tissues throughout the body.

10. The family visited Miss O on 2 September 2023. They describe ‘both feet looking infected, she had swelling up her leg and pus oozing out of her shin.’ They say Miss O advised the district nursing team would be visiting her in a few days’ time.

11. The district nursing team visited Miss O on 6 September.

12. Miss O was taken to hospital at a different NHS Trust on 10 September by her family and she sadly died on 11 September.

District nursing treatment

16. Miss R complains the district nursing team did not appropriately monitor her sister’s wounds. She believes given Miss O’s complex medical history, including vascular disease, she was at high risk of developing an infection. On this basis, she believes the district nursing team should have taken blood tests or tested a swab of her wound to rule out signs of infection.

17. Miss R believes had these proactive measures taken place, the Trust would have identified and treated Miss O’s infection earlier. She believes it would not have led to sepsis, and this may have prevented her death. Miss R is also concerned about the Trust’s record keeping of its home visits to her sister. She says the records are not an accurate reflection of what she saw when she visited her on 2 September.

18. In its response, the Trust said it consulted its medical records and on each home visit, Miss O’s medical records noted no signs of infection.

19. The following guidelines help us to understand what should happen during home visits for wound care.

20. EPUAP guidelines recommends a consistent method for measuring and classifying wound size to allow for comparisons to be made of the wound across time.

21. NICE guidelines CG179 and the International wound guidelines emphasises adults assessed at high risk of developing a pressure sore should have a pressure sore skin assessment, and their care plans should be individualised for their needs.

22. The NMC Code highlights the need to keep clear and accurate records and to accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care. It also emphasises the importance of making a timely referral to another practitioner when any action, care or treatment is required.

23. We reviewed Miss O’s medical records with the help of our nursing adviser.

24. During the home visit on 31 August 2023, the records document two wounds which the Trust cleaned and dressed. It states, ‘no other concerns were raised, wound care delivered to both feet, needs senior review.’

25. The next home visit took place on 6 September, where the Trust documented the length, width, depth and granulation (signs that a wound is healing) of the wounds. It also documented the slough (dead tissue within a wound which appears moist) and exudate (amount of fluid produced by the body to encourage healing) of four wounds. The Trust cleaned and dressed the wounds and arranged a weekly plan for follow up wound care.

26. The Trust did not identify clinical signs of infection on the records. It arranged an action plan to update Miss O’s pressure ulcer prevention care plan, as it was last completed in July 2023.

27. We have seen no evidence in the records that Miss O raised any concerns about her wounds during this home visit or that the nurse noted any concerns regarding the wounds or the state of Miss O’s lower legs in general.

28. Our nursing adviser explains the records are difficult to follow because the wounds are numbered differently between visits and often, not all wounds are documented at each visit. The home visit on 31 August does not classify the wound beds or provide a measurement of the wounds.

29. This information would allow the nurse to make a comparison at the next visit to determine if the wounds are healing or deteriorating. That would also help them consider if the wounds required input from a senior nurse such as a tissue viability nurse (TVN). A TVN focuses on the prevention, assessment, and management of complex wounds and the preservation of the skin.

30. On balance, the Trust’s monitoring of Miss O’s wounds was not in line with the EPUAP guidelines and NICE guidelines CG179. We have also found the record keeping was not in line with the NMC Code.

31. Miss R is concerned given Miss O’s medical history, the Trust should have taken blood tests or taken a swab of Miss O’s wounds as a preventative measure to rule out any concerns of an infection.

32. We asked our nursing adviser about this. They explained while pressure ulcers have a high susceptibility to infection. The process from non-infected to infected is a gradual process and from the records it is difficult to see how quickly or where the original infection originated from.

33. This is supported by Miss O’s hospital records dated 11 September which documents a multidisciplinary meeting (MDT). This was between an Emergency Department (ED) consultant, intensive care unit (ICU) consultant and vascular surgeon. The meeting record said, 'I am not convinced that her foot / lower limbs are the cause of this illness.’

34. Our nursing adviser further explained it would not be routine practice to take blood tests and swabs of Miss O’s wounds as a proactive and/or preventative measure. However, as Miss O had a preexisting condition of lupus, she would have been at an increased risk of developing an infection. Despite this, the International wound guidelines recommend a wound sample should only be collected in the presence of clinical signs and symptoms of a wound infection.

35. Based on this and the Trust not identifying signs of infection on 6 September, it was not required to test Miss O’s bloods or a take a swab of her wound at that time.

36. We have found failings in the Trust’s monitoring of Miss O’s wounds during the home visits, and record keeping. We have considered the impact of this later in the report, as well as our recommendations.

Impact

37. We have investigated Miss R’ concerns the impact of the Trust’s lack of monitoring of her sister’s wounds meant it missed signs of infection. We understand her concerns contributed to Miss O’s death.

38. We reviewed the records from when Miss O went into hospital with the help of our consultant adviser. The care at hospital is not part of our investigation. We have reviewed these records to look into the impact on Miss O of the failings in the Trust’s district nursing care.

39. Miss O presented to the ED, at a different NHS Trust’s hospital on 10 September with symptoms of pain and swelling in the right thigh down to the right lower leg. The records note bruising on her upper leg and mid-thigh, as well as a wound in the right big toe. The hospital also took photographs of Miss O’s feet.

40. The ED noted Miss O’s medical history which included a bilateral lower limb angioplasty, which took place several months prior to this event. This is a procedure used to treat narrowed or blocked arteries in the legs. This requires puncture of the groin artery to give access to the blocked blood vessel.

41. The records document a working diagnosis of sepsis. Input was sought from an ICU consultant and a vascular surgeon consultant. Following this, the hospital transferred Miss O to the critical care unit on 11 September.

42. The records show a telephone discussion with a vascular surgeon based in Oldham stating, 'Agrees that wound wet gangrene could be the source - Advised to stabilise and transfer when safe and if not they will be able to see her in hospital itself tomorrow.'

43. Later, an MDT decided Miss O was too unwell to undergo a lower leg amputation. The MDT was not convinced Miss O’s foot or lower legs are the cause of her illness. Miss O sadly died at 6.55pm.

44. Having viewed the photographs taken of Miss O’s feet, our consultant adviser is of the view the wounds on her feet were superficial ischaemic ulcers and not infected ulcers.

45. Ischaemic ulcers are chronic wounds due to a reduced blood flow to specific areas of the body, primarily the lower limbs. The pictures in Miss O’s records show that these were clean but indolent (showing little sign of healing). There was no redness to suggest a deeper infection or spreading cellulitis (bacterial skin infection).

46. Our consultant adviser explains whilst open wounds will always be exposed to bacteria, the photographs of Miss O’s feet show no significant slough in the wounds and no significant biofilm (bacteria that attach to the wound bed delaying healing of the wound).

47. Our consultant adviser notes Miss O underwent a bilateral lower limb angioplasty several months prior to her admission and they explain sometimes blood can leak out of the vessel causing a localised collection – a false aneurysm (blood clot). When Miss O presented to hospital, she reported feeling unwell with ‘pain and swelling in her thigh. She also reported spontaneous bruising on upper leg and mid thigh.’

48. Our consultant adviser says it is likely Miss O had a blood clot in her right thigh which became infected, and this was likely to be the root cause of sepsis.

49. In terms of how the infection may have entered Miss O’s body is unclear. However our consultant adviser says it is not uncommon for bacteria to have entered via Miss O’s foot ulcers which then caused the infection to develop. They explain this can occur without local signs of infection in the ulcer. Further, Miss O’s pre-existing medical conditions would mean she was at risk to developing infections.

50. Our consultant adviser notes Miss O had very abnormal blood clotting levels (which are crucial for assessing bleeding disorders). She also had a very high international normalised ratio levels (INR - measures how quickly a patient’s blood clots). A normal range is between 0.8 to 1.2. Miss O’s was noted as 7.12.

51. Our consultant adviser explains at these high levels, spontaneous bleeding can occur and recent puncture sites reopen and they consider it is likely Miss O developed a haematoma (collection of blood) in her thigh which became infected. This may have been caused by her angioplasty, or it may have been spontaneous.

52. We understand the family will remain concerned Miss O’s death certificate documents three causes of death including septic shock and infected lower limb ulcer. On this basis they are likely to question why we consider the root cause of sepsis was likely to be in the thigh and not the lower leg ulcer, as documented.

53. Our consultant adviser says Miss O died from septic shock. They also explain death certificates may not always be completely accurate in terms of listing the cause of death in the right order. Miss O was known to have a peripheral vascular disease (a common condition characterised by narrowed arteries that reduce blood flow to the limbs, primarily the legs). She was seen by a vascular surgeon and managed by an acute medical team.

54. The supporting photographs of Miss O’s feet do not display signs of infection. They are superficial and ischaemic. As Miss O complained of pain and a swollen thigh when she presented to hospital, it is appropriate to consider the root cause of sepsis was likely in the thigh. This is supported by her blood results indicating a blood clot.

55. For this reason, on balance we consider it is more likely than not, Miss O developed a haematoma in her thigh which became infected, sadly leading to septic shock.

56. We have found the district nursing records are inconsistent between each home visit. This caused difficulty in monitoring and comparing the wounds, identifying if there has been an improvement or deterioration of Miss O’s wounds and if a referral was required for a review by a senior nurse or TVN.

57. We are deeply sorry to learn about the upset and distress these events caused Miss R and her family. It is clear from our communication with them that this was a very difficult time and it continues to compound their grief.

58. We cannot definitively say the Trust missed signs of Miss O’s foot and lower leg ulcers deteriorating, because the home visit records are not concise or consistent. However, on the balance of probability, the source of infection was more likely than not due to a blood clot in the thigh. This means we have not linked the failings to an impact on Miss O’s death.

59. We recognise if the failings had not happened this would have made a difference to Miss R, as it would have given her reassurances the Trust was monitoring her sister’s wounds appropriately. Therefore we consider the failings caused Miss R distress.

60. We set out our recommendations below.

1. Miss R complains about the district nursing treatment Northern Care Alliance NHS Foundation Trust (the Trust) provided to her sister, Miss O in September 2023. We are very sorry to learn about her concerns and for the loss of her sister. We recognise this has been a very upsetting time for Miss R and her family.

2. We have found the Trust’s record keeping was inconsistent between each district nurse home visit to monitor Miss O’s feet and legs. We also found the lack of clear recording of Miss O’s wounds meant the Trust was not appropriately monitoring whether her wounds were healing or deteriorating.

3. Whilst we have not linked these failings to Miss O’s death, this caused Miss R emotional distress as she was left without the reassurance that the Trust was providing appropriate wound care to her sister.

4. We therefore partly uphold this complaint. We recommend the Trust should issue an action plan explaining what steps it has taken, or will take, to avoid repetition of the failings we have found.