University Hospital Southampton NHS Foundation Trust

7. Mrs R complains about aspects of care and treatment her husband, Mr R received from University Hospital Southampton NHS Foundation Trust (the Trust) between 26 September 2023 and his death on 21 December 2023. In particular, she the Trust:

• failed to identify the severity of Mr R’s condition, • wrongfully referred to orthopaedics and not vascular on 26 September, • delayed MRI scans being carried out, • failed to administer medication on 20 to 21 December, • had issues with communication through the period of care and in particular, between 20 and 21 December; and, • gave Mr R no dignity in death.

8. Mrs R also complains about how the Trust handled her complaint. Specifically, she says there were unacceptable delays and says the investigation was incomplete, with contradicting information. She says the Trust also failed to send her all the requested medical records and says the clinical records were also incomplete.

9. She says the actions of the Trust adversely affected her husband’s quality of life in the final months of his life and ultimately led to his death (his foot should have been amputated). She says her husband was caused a great deal of distress and pain, which caused the family emotional trauma. She says the family have not been given any closure, due to the level of care and undignified end to her husband’s life. She says poor complaint handling added to the distress and upset.

10. As an outcome Mrs R is seeking an acknowledgement of failings (recognition of the lack of duty of care and neglect), an apology, and service improvement (assurances and clarity about what changes will be made to prevent this happening to others in future).

11. Mr R was a 74-year-old gentleman with a medical background including atrial fibrillation (abnormal heart rhythm), high blood pressure, gout (a painful form of inflammatory arthritis) and peripheral neuropathy (numbness below the knees) with no known cause.

12. On 17 September 2023, Mr R was admitted to hospital in France with signs of a serious foot infection. Mrs R says the hospital discharged him on the recommendation that he had surgery as soon as he arrived back in the UK.

13. The hospital in France discharged him on 23 September and he returned home on 25 September, when he was fit enough to do so.

14. On 26 September 2023, the Podiatry team at the Trust saw Mr R and referred him to the orthopaedics department.

15. On 12 October 2023, Mr R attended A&E with a suspected infection in his left foot. The Trust carried out an X-ray of the foot. The Trust said it arranged an MRI scan as an outpatient and informed him to continue antibiotics as his blood results showed indications of an infection.

16. On 23 October 2023, the Trust followed up the referral made by the podiatrist and graded his foot wound as an urgent case, which needed to be seen within two weeks.

17. On 6 November 2023, Mr R saw a cardiologist, and he was deemed fit for surgery.

18. On 11 November 2023, the Trust (orthopaedic team) saw Mr R on 11 November 2023, and arranged for blood tests to be carried out.

19. On 24 November 2023, the vascular team at the Trust saw Mr R. An MRI scan was carried out which showed evidence of bone oedema (when fluid builds up in the spongy inner part of a bone, replacing normal fatty tissue) and soft tissue oedema at the head of the fifth Metatarsal.

20. On 20 December 2023, Mr R was admitted to hospital via ambulance with a suspected chest infection. The Trust carried out a chest X-ray.

21. On 21 December 2023, Mr R sadly died in hospital.

Referral to orthopaedics (September 2023) and assessing/treating Mr R’s condition

25. Mrs R feels her husband should have been referred to the vascular team much sooner and he should not have been referred to orthopaedics when he arrived back from France.

26. She says the vascular team had treated her husband previously, but says the Trust refused the referral because he was not diabetic.

27. The evidence suggests when Mr R returned from France, and he was seen by the podiatry team.

28. We discussed this with our podiatrist who explained Mr R had a history of idiopathic neuropathy (nerve damage due to an unknown cause) and the pictures of his foot dated 26 September 2023 show a very significant ulcer on the outer edge of the foot.

29. Our podiatrist explained there was widespread maceration (the softening and breakdown of skin due to excess moisture) of the surrounding tissue and exposure of deeper softer tissue structures.

30. Our podiatrist went on to say, the trouble in Mr R’s case is that usually these types of ulcerations are due to diabetes where there is a clear pathway for patients, however, Mr R’s ulcers were due to his sensory neuropathy.

31. There is no specific guidance in relation to referrals relating to idiopathic neuropathy. However, it is worth noting Mr R had previously been under orthopaedic care and our podiatrist explained the decision on where to refer him would have been based on clinical judgement.

32. Our podiatrist explained there was nothing in Mr R’s medical notes to suggest there was a vascular problem. They went on to say from the evidence available it does appear it was a bone surgery issue rather than a known vascular problem. This is because, previous X-rays indicate Mr R had his 2nd, 3rd and 4th metatarsal heads removed, which our podiatrist said falls within the jurisdiction of orthopaedics.

33. It is also important to note that once the vascular team reviewed Mr R on 24 November 2023, no vascular intervention was recommended, as the notes suggest there was nothing the department could do.

34. This would suggest that a vascular referral would not have been appropriate had it been made sooner. We are satisfied the referral to orthopaedics was in line with GMC guidance which states;

You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must work in partnership with them to assess their needs and priorities. The investigation or treatment you propose, provide or arrange must be based on this assessment, and on your clinical judgement about the likely effectiveness of the treatment options

• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient, • promptly provide or arrange suitable advice, investigations or treatment where necessary, • refer a patient to another practitioner when this serves the patient’s needs.

35. Based on the evidence we have seen, we are satisfied the decision of the Trust to refer Mr R to the orthopaedics department was appropriate and therefore, we do not uphold this element of Mrs R’ complaint.

36. Mrs R also told our office when she was in France with her husband, staff at the hospital there, recommended half of Mr R’s foot needed to be amputated, and a bone biopsy carried out. She also told us his foot needed to be dressed at least every other day, but this was not done.

37. We discussed this with our orthopaedic surgeon who again explained (along with our podiatrist), Mr R was not diabetic and had longstanding numbness below the knee due to his idiopathic neuropathy. Our orthopaedic surgeon told us this can lead to ulcerations and infections within the foot.

38. Our orthopaedic surgeon explained Mr R was treated with the removal of damaged tissue from the foot and given antibiotics for sepsis. They explained that when Mr R was seen by his GP on his return from France, his records suggest he was ‘well’ and the ulcer had stabilised and there was no sign of it being ‘grossly’ infected.

39. When Mr R attended A&E on 12 October 2023 the Trust carried out X-rays of his foot. Our orthopaedic surgeon told us there did not appear to be any acute changes to the foot from X-rays taken by the Trust on 27 September 2023, or any indication of a bone infection.

40. Our orthopaedic surgeon also explained when the Trust saw Mr R on 12 October 2023, it is documented that the ulcer had mild infection with bone exposed with an element of leg cellulitis (bacteria skin infection).

41. Our orthopaedic surgeon went on to say Mr R overall appeared to be well with mildly elevated blood tests. The Trust subsequently discharged Mr R with a care plan to discuss the planning moving forward and for an MRI scan to be carried out and provided safety netting advice to Mr R to return if he became unwell.

42. Our orthopaedic surgeon said the actions of the Trust appear to be in line with GMC, good medical practice guidance (as set out in paragraph 33).

43. The records suggest the orthopaedic team saw Mr R on 12 October 2023, shortly after returning from France. Our orthopaedic surgeon agreed with our podiatrist that given Mr R did not appear to have any vascular issues (no blood flow concerns) and was not diabetic this was the appropriate route for the Trust to take.

44. On 10 November 2023 Mr R attended the emergency department, and a clinical history was taken. His observations appear to demonstrate he was stable and was not septic. Blood tests show a C reactive protein (CRP) (which measures inflammation in the body) of 18.

45. Our orthopaedic surgeon said this indicated signs of a moderate, low-grade infection but not severe. They explained Mr R’s white blood cell count appeared to be normal.

46. Our orthopaedic surgeon stated a CRP of 18 is a mildly raised marker and likely indicates a chronic issue. However, given there is no indication at this stage Mr R’s white blood cell count was abnormal, and he did not have temperature, our orthopaedic surgeon was satisfied an urgent admission was not required at this stage.

47. On 14 November 2023 the Trust struggled to identify a pulse in Mr R’s foot, so referred him to the vascular team. As previously mentioned earlier in the report, the vascular team saw Mr R on 24 November 2023 where it was deemed, he had normal toe pressure and previous vascular imaging showed no abnormalities. Therefore, he was referred back to the orthopaedic team in line with the GMC, good medical practice guidance, ‘refer a patient to another practitioner when this serves the patient’s needs’.

48. It is unclear from the evidence when the discussion took place, but it appears Mr R was then placed on the vascular waiting list to have a ‘below the knee amputation’. Our orthopaedic surgeon said given the ulcer was stable and was being seen regularly by the Trust, the plan to make the amputation within four weeks was appropriate. The Trust has said the vascular team had better expertise to carry out this procedure.

49. Mr R was due to be seen and checked by the vascular team prior to the amputation and to provide consent to the procedure. However, he was admitted to hospital with a chest infection and sadly died before the procedure could happen.

50. Given there was no indication the condition of Mr R’s foot was worsening the actions of the Trust were appropriate and again, in line with GMC good medical practice guidance.

51. Having considered the evidence there is no doubt Mr and Mrs R were caused a great deal of distress and upset following their return from France, especially given his medical history and the severity of his condition. However, we are satisfied at this stage the Trust made the correct referrals and treated him correctly.

Prescribed medication 20 – 21 December

52. Mrs R says the Trust failed to administer all of Mr R’s prescribed medication (these include, bisoprolol, apixaban (blood thinner), blood pressure tablets, and ‘strong’ pain relief) when he was in hospital on 20 and 21 December 2023.

53. The records indicate an Emergency Department (ED) consultant medically checked Mr R at 10.35am. A cannula for intravenous (IV) medication was prescribed at the same time, and a dose of IV antibiotics was given once the cannula was fitted.

54. It appears a discussion took place between the ED consultant and the medical consultant at 11am. It was agreed medication would not be prescribed until after this discussion. Our nurse explained a nurse can only administer medications once they have been prescribed. This is in line with RPS guidance which state:

‘Records are kept of all medications administered or withheld, as well as those declined such records are completed at the time of the administration/refusal or as soon as possible thereafter and are clear, legible and auditable.

When a medication is not administered or refused, details of the reason why (if known) are included in the record and, where appropriate, the prescriber multidisciplinary team is notified in accordance with the organisational policies and procedures. Appropriate action is taken as necessary’.

55. Our nurse explained the plan included ‘holding’ the use of statins, furosemide (diuretic) and candesartan (used to treat high blood pressure). The medication charts show that these medications were not to be administered until at least 22 December 2023, and therefore, this was the reason the Trust did not administer them. Again, this was in line with the RPS guidance listed above.

56. The medication charts also appear to suggest that apixaban, which was due to be administered twice a day, was administered in the evening of 20 December and the morning of 21 December 2023. Our nurse explained there did not appear to be any delay in administering this medication as the morning dose, from 20 December, should have been self-administered at home, before he was assessed in the emergency department.

57. Our nurse also explained that the rest of Mr R’s ‘morning’ medications, finasteride (used for enlarged prostate), tamsulosin (used to treat urinary symptoms of an enlarged prostate), omeprazole (used to treat acid reflux and heartburn) and bisoprolol were correctly administered on the morning of 21 December 2023.

58. It appears the ‘strong’ pain relief Mrs R has referred to in her complaint Is tapentadol which her husband was taking twice a day prior to admission. The records suggest this was administered in the evening of 20 December and the following morning. Our nurse told us this was administered in line with NICE guidance, which states it should be administered every 12 hours. Therefore, we are satisfied at this stage there was no delay in the administering of tapentadol.

59. In summary, based on the evidence we have seen, we are satisfied the Trust administered Mr R’s medication in line with his prescription and there does not appear to have been any delays.

Dignity in death and communication issues

60. Mrs R has told us that the Trust told her, her husband was not alone at the time of his death but says his medical records suggest otherwise. She says no privacy was afforded to her after his death, and he had been moved from his room, even though she was only 15 minutes away. It was extremely difficult to grieve on a busy ward with no privacy.

61. We discussed this with our nurse who for context explained side rooms are for patients with infection control needs who need isolating. They went on to say if a side room is available for a patient at the end of life, this can be offered.

62. The records suggest Mr R was unwell on admission, however, our nurse explained it did not appear his death was imminently expected. Furthermore, there did not appear to be an infection control issues, therefore he would not have automatically been placed in a side room. This is in line with department of health, in-patient care guidance which states; ‘The ability to isolate components of in-patient accommodation is important for infection control, particularly during outbreaks of infectious illness’

63. On 21 December 2023, the Trust took Mr R’s physiological observations. Our nurse explained his pulse and breathing was raised, but he was still alert and there were no signs for concern or no indication that the Trust needed to contact Mrs R. His National Early Warning Score 2 (NEWS2), which is a tool used by the NHS to quickly assess how acutely ill patients are, was documented as ‘5’. This indicates the following;

‘If the score is between 5-6 this should be an urgent response from the medical team, with the nurse ‘immediately’ informing them. If the patient scores 7 or more across all parameters the nurse must “immediately inform the medical team caring for the patient, this should be at specialist registrar level’.

64. Our nurse said the records suggest the Trust acted in line with the above guidance and there appear to be no concerns.

65. Tragically, less than one hour after the medical review, the records suggest Mr R was found unresponsive and an emergency buzzer was activated. The Trust administered adrenaline but unfortunately, Mr R died.

66. Sadly, it appears from the records that Mr R was alone prior to being found unresponsive, however, as explained his deterioration was rapid and unexpected. We completely understand why Mrs [name redacted] is concerned about this but there is no indication staff should have expected Mr R death or acted differently.

67. Given it appears Mr R died suddenly and the response by the Trust was an emergency response rather than care at the end of life, we are satisfied the Trust acted in line with NMC, the code guidance which states:

13.1 accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care.

13.2 make a timely referral to another practitioner when any action, care or treatment is required.

13.3 ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence.

68. We appreciate why Mrs R is extremely upset about the circumstances before and after her husband’s death and recognise how difficult it must have been not being able to grieve in the privacy of a private room. However, as previously explained it does not appear the Trust could have foreseen his tragic death, and sadly private rooms are not always readily available. Given the sudden nature of Mr R’s death from what we have seen, we are satisfied the Trust acted appropriately and in line with the relevant guidance.

69. Mrs R told us the Trust did not inform her about the rapid deterioration in her husband’s condition. She has said she visited her husband on 20 December 2023 and was to come back in visiting hours the following day.

70. She says had she been notified of her husband’s deterioration sooner, she would have come back to the hospital sooner. However, she says the first call she received from the Trust was to inform her of his cardiac arrest.

71. As we have outlined earlier in the report, there was no indication to suggest Mr R was expected to die. The Trust medically reviewed him less than one hour before he died.

72. There is no indication from the notes that nurses were given any indication from medical staff that Mr R was worsening to the extent where they should contact his next of kin.

73. Therefore, although we fully appreciate the distress Mrs R has clearly been caused by not being present at the time of her husband’s death, we have seen nothing to suggest this was due to errors made by the Trust.

MRI scan delays

74. Mrs R says the Trust delayed carrying out an MRI scan. She says her husband initially received an appointment for 12 November, but it was cancelled because a spinal cord stimulator representative needed to be present and the MRI was then rescheduled for 24th November, but again, no representative was present.

75. Mrs R says they never received the results once the MRI scan had been done.

76. The Trust explained a nerve stimulator should be mentioned on an MRI booking request. However, it says this was omitted and the clinical notes only mentioned a metallic implant. Different stimulator implants have their own requirements for safe imaging, so this had to be confirmed before the scan could go ahead. The Trust has apologised that this error led to a delay in the scan taking place.

77. The Trust said the scan eventually took place on 24 November 2023 and the delay did not have any impact on Mr R’s treatment.

78. We discussed this with our orthopaedic surgeon and asked if the delay had any lasting impact on Mr R and his ongoing treatment.

79. Our orthopaedic surgeon explained the MRI scan on 24 November 2023 shows bone oedema/soft tissue oedema (fluid accumulation and inflammation in bones or in the surrounding tissues) and erosive changes suggestive of infection.

80. Importantly there was no evidence of soft tissue collection (an abnormal, localised accumulation of fluid). They explained soft tissue collection can occur with severe infection and may require urgent surgical treatment, as the situation appeared to be stable. However, it does not appear treatment was required as Mr R required a below the knee amputation.

81. Our orthopaedic surgeon explained the changes described on the MRI scan would be expected given the clinical appearance of the ulcer (from the images 24 November 2023). An MRI scan also helps determine the appropriate amputation level and may help with pre-operative planning.

82. When Mr R attended A&E on 20 December 2023, he was seen by doctors. They did not want to admit him to hospital until they knew it was not the foot causing the infection, so an X-ray was arranged.

83. Our orthopaedic surgeon said the evidence suggests the foot was ‘stable and not severe’ and shows the Trust assessed the foot, with no signs of significant infection. The main concern at this point was Mr R’s chest.

84. Ultimately, it appears the Trust admitted Mr R with a pneumonia/pulmonary fibrosis (a chronic, progressive lung disease) with a background of heart failure that led to a very quick deterioration.

85. Although there was a delay in carrying out the MRI scan this had no lasting clinical impact on Mr R. We do appreciate this would have caused him and Mrs R a great deal of distress, frustration and upset at the time, given his poor health. However, the Trust has since apologised for its error and for the frustration caused.

86. As such, we are satisfied it has taken appropriate steps to put things right at this stage.

87. This is in line with NHS complaint standards, which state: ‘Organisations support and encourage staff to be open and honest when things have gone wrong or where improvements can be made. Staff recognise the need to be accountable for their actions and to identify what learning can be taken from a complaint. They are clear about how the learning will be used to improve services and support staff’.

88. We have also looked at Mrs R’s concerns about not being given the MRI scan results.

89. From the information we have seen, there does not appear to be any correspondence between the orthopaedic and vascular teams between 24 November (day of the MRI scan) and 19 December 2023. However, during this time the vascular team agreed to perform the ‘below the knee amputation’, as it did these procedures more regularly. The amputation was also discussed with Mr R on 24 November 2023.

90. As such, there is no evidence at this stage to suggest the Trust made Mrs and Mr R aware of the MRI results. However, as with the delay in carrying MRI, we are not convinced this had any significant impact, given the Trust had taken the appropriate steps to perform an amputation procedure.

Complaint handling and issues with clinical records

91. Mrs R has also raised several issues about the way the Trust handled her complaint. Specifically, she has said there were delays in providing her with responses and says there were unresolved concerns.

92. We can see Mrs R initially raised her complaint with the Trust on 1 January 2024. The Trust acknowledged the complaint on 4 January and said it would provide a full response by 4 March 2024.

93. However, on 4 March 2024 the Trust wrote to Mrs R and said unfortunately, it needed more time respond as further information was required. It apologised for the delay and thanked Mrs R for her patience. The Trust issued a full response on 26 March 2024.

94. Mrs R subsequently responded in detail on 22 April, raising several questions. The Trust acknowledged this the following day and raised the possibility of having a meeting with Mrs R, to discuss her outstanding concerns.

95. Mrs R declined the offer and asked for the Trust to respond in writing. The Trust responded on 26 April and said it would obtain information from her husband’s GP practice and respond in writing.

96. The Trust issued its final response on 19 July 2024 and referred Mrs R to our office.

97. NHS complaint standards state: ‘Staff should respond to complaints at the earliest opportunity and consistently meet expected timescales for acknowledging a complaint. They give clear timeframes for how long it will take to investigate the issues, taking into account the complexity of the matter’.

98. The standards also state: ‘Staff should give a clear, balanced account of what happened based on established facts’.

99. Based on the evidence we have seen, we are satisfied the actions of the Trust were appropriate in the way it handled Mrs R’s complaint, and it acted in line with NHS complaint standards.

100. Although, the Trust did not issue a response to Mrs R in the timescales initially agreed, it did contact her to make her aware and there was a slight delay, and it apologised for this. It subsequently issued its response shortly after, which we cannot criticise.

101. Furthermore, we are satisfied the responses provided by the Trust were appropriate and covered the main points of complaint raised by Mrs R and were issued in line with complaint standards. We recognise Mrs R’s concerns and the frustration the short delay must have caused, but based on what we have seen, we do not uphold this part of the complaint.

102. Finally, we looked at Mrs R’s concerns that when she requested her husband’s records from the Trust, they were incomplete and not in date order.

103. The Trust explained in its response to Mrs R all the relevant information should have been included. It has apologised if it provided inaccurate information regarding communication surrounding her husband’s death.

104. It is unclear specifically what information Mrs R feels was missing at this stage however, given the Trust has apologised for any distress caused and given there does not appear to be any lasting impact we are satisfied the Trust has done enough to put things right in line with NHS complaint standards.

105. In conclusion we understand and deeply empathise with Mrs R concerns in bringing this complaint to us, particularly given the severity of her husband’s condition and subsequent tragic death. However, although, we acknowledge Mr R was provided clinical advice whilst he was in France, we have found the Trust acted in line with the relevant guidelines and therefore do not uphold the complaint.

1. We have carefully considered Mrs R’ complaint. We are sorry to hear of the tragic death of her husband, Mr R and the circumstances leading up to his death. We also appreciate the reasons why Mrs R brought her complaint about the Trust to our office.

2. We found the referral by the Trust to orthopaedics was appropriate and we are satisfied the care provided by the podiatry team was also appropriate and in line with the applicable guidance.

3. We also find the Trust acted appropriately in relation to administering Mr R’s prescribed medication and we are satisfied it acted in line with guidance in respect to care provided at towards the end of his life. The evidence suggests there was no indication Mr R was going to die so suddenly, and therefore, nothing to suggest the Trust should have contacted his wife any sooner than it did.

4. Furthermore, we are satisfied the Trust acted appropriately when assessing and treating Mr R’s condition and acted in line with the relevant standards. We also found the delay in the Trust carrying out an MRI scan had no lasting impact on Mr R.

5. We also found the Trust handled Mrs R’ complaint appropriately and in line with relevant guidance. We think it took too long to issue the response, but this is not serious enough to amount to maladministration.

6. Based on the evidence we have seen, we do not uphold Mrs R’ complaint. We know how deeply Mrs R has been affected by these events and her husband’s tragic death. We hope our report fully explains the reasons for our decision and provides her with some closure.