Leeds Community Healthcare NHS Trust

3. Mr K complains about the community nursing care he received from Leeds Community Healthcare NHS Trust from November 2024 to February 2025.

4. Mr K says staff failed to identify and treat his pressure ulcers and allowed them to deteriorate.

5. Mr K says his wounds deteriorated due to the Trust’s inaction and he was admitted to hospital for nine weeks. He says the experience has affected his independence and confidence. Mr K says he has also missed holidays and time with family due to the time spent in hospital.

6. Mr K would like the Trust to make improvements to its service and pay him a financial remedy.

7. Mr K is paraplegic and uses a wheelchair. He has been a patient at the Trust since 2011 and receives a visit from the community nursing team every eight weeks for routine suprapubic catheter changes and a pressure risk assessment.

8. In November 2024, Mrs K’s wife contacted his GP Practice as he had a sore area on his sacrum (the bone at the base of the spine). The GP conducted a visit one week later and noted extensive moisture damage and a pressure ulcer on Mr K’s sacrum.

9. The GP then made a referral to the community nursing team at the Trust who visited four days later to dress Mr K’s wounds and conduct a full wound and pressure risk assessment.

10. The Trust referred Mr K for a specialist review by a Tissue Viability Nurse (TVN), who visited the following week and updated the risk assessment and management plan. The TVN also identified that the pressure ulcer had deteriorated and discussed a repositioning schedule with Mr K.

11. Mr K’s wounds continued to deteriorate over the following months despite regular visits from the community nursing team. In February, Mr K was admitted to a local hospital as his wounds had developed sepsis. Mr K remained in hospital for the next nine weeks until he was discharged.

16. 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 done this and have not found any indications that something has gone wrong.

17. Mr K said the Trust failed to identify and treat his pressure ulcers and allowed them to deteriorate.

18. The Trust said all staff involved in Mr K’s care were aware of the risks and potential for deterioration in his condition. It said staff completed all pressure risk and wound assessments in accordance with its pressure ulcer prevention and management policy.

19. The Trust explained staff visited Mr K every two days between Monday and Friday each week following the assessment by the TVN, to dress the wounds and carry out observations. It said staff also gave Mr K and his wife (who he had asked to dress the wounds at the weekend) advice on repositioning, information on risks and when to escalate.

20. The Trust said Mr K’s paraplegia and inability to feel sensation below the Thoracic 4 vertebrae (an area of the spine) in addition to type 1 diabetes affects the risk of pressure ulcers and can delay wound healing. It added the use of a wheelchair when trying to heal a wound to the sacral area is very difficult and relies on bed rest and continuous offloading.

21. The records show in October 2024, nursing staff carried out a detailed skin check and noted that the skin around the sacrum and buttocks was normal but vulnerable to pressure damage. Community nursing staff were next due to attend Mr K in December, but the spinal injuries team identified a sore area during an appointment at the beginning of November and Mr K reported this to his GP Practice a week later.

22. The Practice then made a referral to the community nursing team, and the nursing team promptly arranged a visit two days later.

23. NICE guidelines on prevention and management of pressure ulcers explains clinicians should:

‘develop and document an individualised care plan for patients who have been assessed as being at high risk of developing a pressure ulcer, taking into account:

• the outcome of risk and skin assessment • the need for additional pressure relief at specific at-risk sites • their mobility and ability to reposition themselves • other comorbidities • patient preference.’

24. Additionally, the Trust has its own policy on pressure ulcer prevention and management which explains staff should carry out a ‘Purpose T’ assessment when there is a risk of skin damage.

25. A Purpose T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) is an evidence-based clinical framework used to assess an adult’s risk of developing pressure ulcers. It involves a full visual skin inspection of all areas that are vulnerable to pressure, shear and friction. Shearing occurs when layers of tissue and skin move in opposite directions, which can result in deep tissue or muscle damage.

26. Community nursing staff completed the Purpose T assessment on the first visit in November after Mr K had reported the skin damage to his GP Practice. Staff recorded moisture associated skin damage (MASD) and shear to the sacrum and buttocks, which was worse when transferring, and completed a wound assessment template.

27. Following the assessment, the Trust ordered a high-risk foam cushion for Mr K, which is designed to prevent pressure ulcers for individuals with limited mobility who spend prolonged periods seated.

28. The Trust noted that Mr K was independent and self-caring with repositioning, which means he was able to do this himself. The Trust advised Mr K to reposition every two to four hours and arranged for visits to take place every two days. Our nursing adviser said this management plan was in line with the Trust’s policy.

29. The Trust also made a referral to the tissue viability nurses (TVN – specialist practitioners who focus on skin integrity and the prevention, assessment and management of complex or hard-to-heal wounds). The Trust also made a referral to the occupational therapy team (OT) for an assessment of transfers and equipment, to understand the cause of Mr K’s MASD.

30. The NMC Code says nursing staff should:

• ‘accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care • make a timely referral to another practitioner when any action, care or treatment is required • 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’.

31. Our adviser said nursing staff correctly identified the risk to Mr K’s skin that would require specialist intervention from a TVN and OT, and made the referrals in a timely manner, in line with the NMC Code.

32. The TVN reviewed Mr K’s notes and the photographs the nursing staff had taken and advised a stricter repositioning schedule of every two hours. The TVN updated the management plan.

33. Over the following two months, community nurses regularly visited Mr K every two days to dress his wounds and continued to document wound assessments in line with the Trust’s policy.

34. In January 2025, Mr K reported to staff that he had been feeling unwell and had a temperature. Nursing staff took clinical observations but noted there were no signs of infection, although there was a strong odour from the wound. Staff then escalated to Mr K’s GP Practice and the Practice prescribed him with antibiotics.

35. The NICE guidelines on pressure ulcer prevention and management say in the event of a deterioration after a skin assessment, offer systemic antibiotics to adults with a pressure ulcer if there are any of the following:

• clinical evidence of systemic sepsis • spreading cellulitis • underlying osteomyelitis (bone infection).

36. The Trust referred Mr K to a senior TVN for specialist wound care due to concerns about possible bone osteomyelitis. The TVN visited and arranged with Mr K’s GP for further antibiotics, wound swabs and blood tests. This shows Trust staff were continuing to manage the risk to Mr K and were escalating in a timely manner.

37. The TVN visited again at the beginning of February in a joint visit with the community nurse. At this stage neither staff member noted any signs of infection, however they provided Mr K with advice on the signs to look out for and what action to take.

38. Six days after this joint visit, Mr K’s wife identified there was a deterioration in Mr K’s health and contacted NHS 111. Mr K was then admitted to hospital and treated for sepsis.

39. We understand Mr K is concerned that as he contracted sepsis despite having regular visits from nursing staff, this was avoidable. We recognise Mr K had a lengthy hospital admission and missed out on family occasions and a holiday. It is clear this experience has had a huge impact on Mr K and his daily life even following his discharge from hospital.

40. Based on the evidence we have seen, Trust staff did not identify Mr K’s pressure ulcers and MASD, however there was no opportunity for them to do so as Mr K had self-reported to the GP following the appointment with the spinal injuries team.

41. Once they had been identified, the Trust acted in line with relevant guidelines and its own policy to manage, monitor and treat the pressure ulcers and MASD. When they began to deteriorate, the Trust escalated the situation in a timely manner to the appropriate practitioners.

Conclusion

42. We understand the devastating impact Mr K’s experience has had and continues to have on him. Mr K has told us of the amount of time he has had to spend on bed rest with little social life, and the things he has had to cancel, including holidays and his season ticket for his local football team. We appreciate Mr K feels that the Trust is responsible for this.

43. We hope our work will provide Mr K with some reassurance that the Trust treated his symptoms with the right level of seriousness and we have seen no indications the Trust did anything wrong.

1. We have carefully considered Mr K’s complaint about the Trust. We understand this was a very difficult situation for Mr K and he has spent a lengthy period of time in hospital recovering.

2. We have reviewed all the available evidence, and we have seen no indications the Trust did anything wrong.