East Sussex Healthcare NHS Trust

5. Mrs A complains the Trust failed to provide treatment to her father, Mr B, following a flare up of bullous pemphigoid in August 2024.

6. Specifically, she says:

• the Trust failed to communicate effectively with Mr B between 21 and 27 August when his condition worsened and therefore left him without treatment • once Mr B was admitted to the Trust, it failed to provide adequate treatment for his skin condition and delayed making a referral to the dermatology team between 27 and 29 August.

7. She says the lack of timely treatment caused a loss of opportunity for recovery. She says her father developed sepsis, and kidney failure which led to a deterioration in his health and contributed to his death in September 2024. She says the missed opportunity for a better outcome and the loss of her father continues to cause her significant distress.

8. She is seeking an acknowledgement of failings and service improvements.

9. Mr B had a history of bullous pemphigoid (a skin condition which causes sores and blisters). The Trust’s dermatology team had previously prescribed 17mg of prednisolone (a steroid medication).

10. Mr B had a flare up of blisters at home and Mrs A emailed pictures of this to the dermatology team on 21 August 2024.

11. On 22 August, Mr B attended the ED, and staff informed him they could not reach the dermatology department for advice as it was out of hours. The Trust says as Mr B attended at 7.30pm, the department was closed.

12. ED clinicians prescribed 500mg flucloxacillin (an antibiotic) four times a day for seven days. They did not need to admit Mr B, as they said his condition was stable and Mr B and Mrs A were happy to contact the dermatology department the following day to review the treatment plan.

13. Mrs A again informed the dermatology department by email of Mr B’s worsening condition, and included photographs, on 23 August and 27 August, with no response.

14. The Trust admitted Mr B to hospital on 27 August to the ED with kidney failure and suspected sepsis (a life-threatening condition caused by the bodies extreme reaction to an infection).

15. The dermatology team wrote to Mr B’s GP on 28 August, to advise it to increase prednisolone to 30mg, then reduce to 1mg a week, but Mr B was already an inpatient at the Trust at this time.

16. Mr B’s condition deteriorated on the evening of 28 August, and the medical team and on call doctor reviewed him. They made a plan to refer Mr B to the dermatology team.

17. On 29 August, clinicians made a ward referral to the dermatology team. The referral sought dermatology input on whether to restart a cream to treat the skin, guidance on the choice of antibiotics, and a steroid management plan.

18. The dermatology team reviewed Mr B on 30 August and increased prednisolone to 50mg a day and prescribed a steroid cream.

19. Mr B sadly died in mid-September 2024 from pneumonia.

Outpatient care

23. Mrs A is concerned the dermatology department did not respond when she emailed to say her father’s skin condition got worse between 21 and 27 August therefore, Mr B was left without any treatment.

24. The Trust says the consultant overseeing Mr B’s care responded to her email at the earliest opportunity on 30 August, as they are employed part time.

25. It said the administration team should have responded to Mrs A’s email to let her know there would be a delay in response from a consultant due to availability and apologised this did not happen.

26. We understand from our dermatology adviser, there is no specific guidance on the timescales for a contact from a consultant when a patient contacts the team by email.

27. Our principles say public bodies should give people information and, if appropriate, advice that is clear, accurate, complete, relevant and timely.

28. Mr B’s consultant was not available when Mrs A contacted asking for advice. We think the dermatology administration team did not act in line with our principles when it did not respond to Mrs A’s emails, when she asked for advice on Mr B’s worsening condition. We think it should have contacted her to advise there would be a delay in response from the consultant and signpost her to Mr B’s GP or the ED if he needed urgent care or treatment.

29. We understand how deeply worried Mrs A was about her father being at home. We appreciate how distressing and upsetting this must have been for her.

30. Whist we have seen an indication of a failing in the way the Trust did not respond to Mrs A or signpost her to other services, we cannot say any clinical impact arose from it.

31. This is because if the Trust had responded to Mrs A, it would have recommended they contact Mr B’s GP or attend ED if Mr B required treatment.

32. Mrs A acted quickly by taking Mr B to the ED on 22 August, just one day after her initial contact with the dermatology team. Her proactive decision ensured Mr B received antibiotics and prevented any delay in care.

33. We acknowledge that waiting for a response from the dermatology team at such a worrying time must have been distressing for Mrs A. However, it is clear that her prompt actions ensured clinician’s reviewed Mr B, and he received antibiotic treatment without delay.

34. We acknowledge Mrs A made further attempts to contact the dermatology team after the initial ED admission. Given that ED clinicians had recently reviewed Mr B and he was still on antibiotics during this time, we do not think there was a further clinical impact.

35. For these reasons, we will take no further action on this part of Mrs A’s complaint.

Inpatient care

36. Mrs A thinks once the Trust admitted Mr B, clinicians did not do enough to treat Mr B’s skin condition, and it should have referred him to the dermatology department for specialist input earlier than it did.

37. GMC guidance ‘Good Medical Practice’ paragraph seven, says doctors should ‘promptly provide (or arrange) suitable advice, investigation or treatment where necessary.’

38. The Trust admitted Mr B on the evening of 27 August with suspected sepsis.

39. NG51 says when sepsis is suspected, clinicians should administer intravenous (IV) fluids and antibiotics. IV means fluids and medications given directly into a vein.

40. We can see from Mr B’s medical records ED staff administered IV fluid treatment and flucloxacillin (an antibiotic), which we understand from our physician adviser was appropriate to treat his infection.

41. Therefore, we think in providing the initial treatment for suspected sepsis, the Trust acted in line with NG51.

42. Dermatology guidelines say systemic corticosteroid therapy (treatment that uses synthetic drugs to mimic the body’s natural stress hormones) is the standard treatment for bullous pemphigoid, with prednisolone being a common medication. The dose can be adjusted according to the severity of the condition and clinical response.

43. A consultant reviewed him at 11.20am the following morning and continued his usual dosage of prednisolone to treat his skin condition.

44. Mr B’s clinical condition was stable at the time. When a patient is stable, it typically means their symptoms or condition are under control, so there’s no immediate need to change the medication dosage. For this reason, our physician adviser explained the clinician’s decision to not adjust the steroid dosage at that time was appropriate as his infection was under control and he was continuing with medication to treat his skin condition.

45. GMC guidance requires that clinicians arrange specialist advice or investigation ‘where necessary.’ At that stage, there was no clinical indication that dermatology input was necessary, as Mr B’s condition was stable with the treatment he was receiving.

46. Mr B’s medical records show late in the evening of 28 August, his national early warning system (NEWS) score, which is a score to monitor a patient’s overall condition, began to increase. This indicates his condition had begun to deteriorate.

47. It must have been a deeply concerning time for Mrs A and those who cared for him.

48. The critical care outreach service and medical team assessed Mr B at this time and, identified his condition had changed, and submitted an urgent referral to the dermatology team for a review.

49. GMC guidance requires doctors to act promptly in providing suitable advice or treatment in response to a patient’s changing condition. In line with this, the team appropriately escalated the situation and sought dermatology input without delay, when he required it.

50. The dermatology team acted on the referral and a dermatologist reviewed him the following day where they increased Mr B’s steroid dosage to 50mg, which was appropriate treatment.

In summary, we have seen no clear indications clinicians failed to adequately treat Mr B’s skin condition and did so in line with GMC and dermatology guidelines. We also think there was no clinical need for clinicians to refer Mr B to dermatology earlier than they did, and when his condition deteriorated, it acted in line with GMC guidance and promptly referred him to the dermatology team.

51. For this reason, we will take no further action.

52. We understand why Mrs A felt that dermatology input should have been sought earlier, given the seriousness of Mr B’s condition and it was clearly a distressing time for her.

53. Having reviewed the available evidence, we are satisfied that clinicians acted in line with GMC guidance based on Mr B’s condition and they prioritised specialist involvement as soon as it became necessary.

1. We have carefully considered Mrs A’s complaint about East Sussex Healthcare NHS Trust (the Trust).

2. We acknowledge the profound impact the loss of Mr B has had on Mrs A, and we offer our sincere condolences for her loss.

3. We think the dermatology administration team should have advised Mrs A there would be a delay in response from a consultant and to attend the emergency department (ED) or GP if Mr B needed urgent treatment. We do not think there is any impact arising from this as Mr B attended the ED the following day.

4. We have also found no indications of failings in the way the Trust treated Mr B or managed its referral to the dermatology team, during Mr B’s admission.