Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust

6. Miss N is complaining about the Trust’s care of her father, Mr N, during his admission from 16 September to 1 October 2023.

7. She complains that the Trust: • delayed starting antibiotic treatment for C-diff as soon as it suspected Mr N had this diagnosis • did not properly dress his skin tears.

8. She says as a result of: • the delay in starting antibiotic treatment, he developed sepsis and this contributed to his death • the failure to properly dress his skin tears, he developed arm ulcers which also contributed to his death.

9. She would like the Trust to acknowledge the failings in her father’s care and pay a financial remedy to recognise the upset caused to her and her sister.

10. Mr N had a previous admission at the Trust from 10 to 11 September 2023 for treatment of pneumonia which had developed from a Covid infection.

11. This complaint concerns his subsequent admission from 16 September. Mr N’s GP referred him to the Trust because he was becoming dehydrated due to diarrhoea.

12. The Trust prescribed the antibiotic, vancomycin, between 18 and 28 September for a confirmed diagnosis of C-diff.

13. The Trust also treated his skin tears on both elbows during the admission.

14. From 27 September Mr N’s condition deteriorated and he sadly died on 1 October.

15. Mr N’s death certificate says the main cause of his death was multi-organ failure. Sepsis and arm ulcers were two of the contributory factors.

Treatment of C-diff

20. C. diff is a type of bacteria which causes severe inflammation of the colon and watery diarrhoea. It typically occurs when antibiotics disrupt the balance of good bacteria in the gut.

21. NG199 sets out the recommendations for treatment of C-diff. It says that oral vancomycin is the recommended antibiotic therapy for either suspected or confirmed C-diff, if it is not severe.

22. Mr N’s records from the time of his admission show the doctors were unsure if Mr N had either gastroenteritis or C-diff and for this reason did not immediately prescribe antibiotics. They sent a sample for testing on 16 September. The sample came back with a positive result for C-diff on 18 September and the doctors prescribed a course of oral vancomycin at that point.

23. In this case Mr N was elderly and on steroids. As such he was a vulnerable patient. He had also recently completed a course of antibiotics which are known to cause C-diff and his diarrhoea was typical of the condition. Given these factors, it would have been in line with NG199, to have commenced antibiotics on 16 September on the basis staff suspected C-diff, pending a definitive diagnosis from the sample.

24. As this is not what happened in Mr N’s case, we considered whether it was reasonable for the Trust to wait the two days before it gave him the vancomycin. We understand the delay has caused Miss N significant worry and concern.

25. In Mr N’s case our physician adviser explained it was also reasonable to delay prescribing Mr N antibiotics until diagnosis was confirmed. This is because his condition was relatively stable on the day of his admission. This is evident from his records at the time of his admission.

26. Firstly his C-reactive protein (CRP) level was 47. CRP is a protein in the blood and high levels typically indicate an infection. The normal range is between zero and five but can go up to 400/500. Our physician adviser explained this level was still low and suggested it may have resulted from Mr N’s recent Covid and pneumonia infections remaining in his body, rather a new infection.

27. Mr N’s records also show he had no abdominal pain, no significantly high or low blood pressure, low blood PH balance or low blood oxygen levels. As such there was no indication he had systemic sepsis. This is a life threatening condition requiring emergency medical treatment. It occurs when the immune system overreacts to an infection and triggers a chain reaction that damages the body’s tissues and organs.

28. Our physician adviser also explained many microbiologists encourage staff to get a diagnostic confirmation of infection before commencing treatment. This is because there are other causes of diarrhoea. As such clinicians may run the risk of treating someone unnecessarily with the incorrect antibiotic which could potentially kill off their good bacteria and/or cause unnecessary side effects. In this case the doctors considered that gastroenteritis may have been responsible for Mr N’s symptoms and wanted to confirm the diagnosis either way before starting treatment.

29. We understand Miss N is concerned that the Trust delayed her father’s treatment. Having carefully considered the evidence set out above, we have not seen any indication of failings in the Trust’s decision to wait until 18 September before it gave Mr N vancomycin. We hope our consideration provides reassurance to Miss N.

Dressing of skin tears

30. Miss N complains the Trust failed to properly dress Mr N’s skin tears on his elbows. She is concerned this resulted in the ulcers he developed, which contributed to his death.

31. CG179 is the relevant guidance to help us understand how staff should assess adults at risk of skin damage with a view to preventing pressure ulcers.

32. It says that that adults who have been assessed as high risk should receive a skin assessment from a trained health care professional.

33. The Trust carried out an assessment of the risk of pressure ulcers resulting from Mr N’s skin damage on the first day of his admission and determined he was ‘at risk’. It subsequently referred him to a tissue viability nurse (TVN) in line with CG179.

34. A TVN is a nurse who specialises in the prevention of wounds and the management of complex or slow healing wounds. They provide expert advice to clinicians on the best treatments, dressings, and equipment.

35. Our nurse adviser says they would have expected the TVN to develop a specific care plan setting out the requirements for ongoing management of the skin tears on Mr N’s elbows including any dressing requirements.

36. NICE BNF also sets detailed guidance about how to assess the type of dressing most appropriate for a wound. It explains this depends on the type of wound and the stage of the healing process.

37. In this case we would have expected the TVN to have advised nursing staff how to most appropriately dress Mr N’s elbows in line with NICE BNF. We saw no evidence of this in Mr N’s records.

38. We would also expect nursing staff to have implemented the TVN’s recommendations in line with the Code which says nurses should demonstrate the ability to work in partnership with people to continuously monitor, evaluate and assess the effectiveness of all agreed nursing care plans, documenting progress and decisions made.

39. With the above in mind we have reviewed the references to Mr N’s dressings in his records as follows.

40. From his records, nursing staff: • redressed his elbows on 18 September • left the dressings in place on 19 September • redressed both on 21 and 24 September • redressed his left elbow only on 26 September.

41. The medical examiner’s review refers to the dressings applied to Mr N’s elbows on 27 September. It says ‘there is purulent discharge underneath and in places oozing out of the duoderm dressings. Purulent describes something that contains or produces pus and commonly refers to the fluid or discharge from a wound. The duoderm dressings were sticking to the skin and difficult to remove however without causing skin tears’.

42. On 28 September there was a clinical review of the wounds due to ‘soiled dressing and pus like exudate’. Exudate is the fluid that comes out of a wound. The entry in the records continues ‘The wounds were ‘left open at present as dressings causing more trauma to skin due to fragility’.

43. On 29 September, nursing staff applied an atrium mesh dressing to both elbows.

44. Both duoderm and atrium mesh are types of dressings typically used on skin wounds. NICE BNF sets out the appropriate use of both types of dressing in wound care.

45. From our review we can see there is some evidence that nursing staff attended to the dressing of his elbows.

46. Also from the above it appears that duoderm was used on and possibly prior to 27 September and atrium mesh on 29 September.

47. We have not seen any evidence setting out the Trust’s rationale for the choice of dressing and there are insufficient entries in the records to tell us what dressing was in place for the majority of the time or how often it was reviewed and/or changed. There is also a lack of consistent documentation of the type of wound to identify if either atrium mesh or duoderm was appropriate when we can see one or the other was used.

48. In summary from the available evidence we consider the Trust carried out the appropriate actions in line with CG179 to initially assess the skin damage on Mr N’s arms and make a referral to the TVN.

49. However, we have not seen enough evidence of the subsequent management of Mr N’s dressings to reassure us that the Trust followed guidance here. We cannot therefore say nursing staff changed the dressings properly or used the appropriate dressings. As such we consider there is an indication of a failing.

50. We understand Miss N was very distressed to see the infections forming on Mr N’s elbows as described above. It must have been incredibly difficult to see her father develop ulcers during his admission. We see the reference to arm ulcers on his death certificate has understandably left her anxious that the incorrect dressings caused the infections and potentially resulted in her father’s eventual death.

51. We have carefully considered what happened. We cannot say that the Trust’s actions definitely caused Mr N to develop ulcers given he was at risk of developing them from the time of his admission.

52. We recognise Miss N is very concerned that her father’s arm ulcers developed into sepsis and we hope the following is helpful to her.

53. Mr N’s death certificate shows the condition that caused his death was multi organ failure. It lists sepsis, along with heart disease, as the factors that contributed to that. It then has chronic leg and arm ulcers, along with pneumonia, at ‘1c’ on the death certificate. This means the doctor considered Mr N’s leg and arm ulcers and chest infection contributed to his sepsis.

54. From the available evidence it does appear that Mr N was developing sepsis and potentially any type of infection can result in this condition.

55. However in Mr N’s case it does not appear sepsis developed either as a result of his C-diff or skin infection. Mr N’s post mortem diagnosis said the sepsis likely resulted from a urine infection.

56. Mr N’s post mortem showed he had vancomycin resistant enterococcus.

57. Our physician adviser tells us it is very hard to treat this strain of bacteria which tends to affect people with weakened immune systems. Unfortunately Mr N may have developed this due to the appropriate use of vancomycin to treat his diagnosis of C diff. He was very ill and frail and sadly it appears the infection overwhelmed him. We have therefore not made a link between the way staff dressed Mr N’s elbows and him developing sepsis.

58. We recognise Miss [name redacted]’s concerns about her father’s care have been very upsetting for her. We hope our consideration of her complaint goes some way to providing her with clarification and reassurance.

1. We have carefully considered Miss N’s complaint about Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust (the Trust).

2. We are very sorry for her loss and to hear about the sad circumstances of the last days of her father’s life.

3. Having reviewed all the available evidence, we have not seen any indications that the Trust did not provide appropriate care for her father’s diagnosis of clostridium difficile (C-diff) in line with relevant standards and guidance.

4. In respect to the part of her complaint relating to her father’s dressings, there is a lack of available evidence to reassure us that the Trust provided appropriate care. However we have decided we cannot say any indications of failings here directly resulted in the impact Miss N has described.

5. As such we do not intend to take any further action. We have explained our thinking in more detail below.