West Suffolk NHS Foundation Trust

4. Mrs B complains about aspects of the care and treatment the Trust provided to her husband, Mr B, between December 2024 and February 2025. Specifically, she says that: • staff did not care for his skin properly or in line with his existing cellulitis and ulcer management plan • nurses failed meet her husband’s hygiene and repositioning needs, particularly in light of his dementia.

5. Mrs B complains her husband died in agony due to poor skin care. His lack of personal care was incredibly distressing.

6. She explains she remains devastated due to the loss of her husband and her distress at the poor care he received has added significantly to her bereavement.

7. Mrs B would like the Trust to acknowledge what went wrong and apologise for the impact this had on her and her late husband. She is also seeking improvements in the way the Trust cares for patients with dementia.

8. Mrs B’s husband, Mr B, was an 87 year old man. Although he had dementia, Mrs B told us he still enjoyed life, and continued to be good with people. This made him popular at his GP practice, which he attended regularly. He had cellulitis (a bacterial skin infection) and heel sores which a nurse at his GP surgery dressed weekly.

9. In December 2024, Mr B became unwell with a suspected urinary tract infection. He became unresponsive on 26 December and the Trust admitted him for investigations and treatment for a newly diagnosed flu. On 4 January he developed sepsis (an extreme response to infection). On 30 January it discharged him to his home with a hospital bed and care package. Two days later Mr B fell out of bed and injured his leg. The Trust readmitted him via ambulance.

10. Sadly, Mr B was very unwell and doctors told Mrs B he was reaching the end of his life. On 18 February the Trust discharged him with support in line with his and Mrs B’s wishes. He died at home on 26 February.

14. Mrs B told us she did not feel the Trust’s nursing staff always took into account her husband’s dementia. She explained she overheard a nurse saying he always shouts ‘Help me’, so to ignore it. The Trust’s records show he regularly shouted this. Mrs B acknowledged he did this, even when he already had the help he wanted, but this was not his fault because he could not remember. She warned staff he might not always want to cooperate with care which he needed, and she encouraged them to carry out this care even when he was resistant.

15. We recognise that some types of nursing care can feel intrusive, uncomfortable, or unwelcome, and for many reasons patients may decline beneficial care. Mr B’s records show he was more frequently agitated after 4 January, when he had sepsis. He more frequently refused dressing changes, skin checks and repositioning after this date. To force him to receive this care if he was physically resisting, staff would have had to use restraint.

16. There are limited occasions when nursing and clinical staff can use restraint - a form of deprivation of liberty. The DoLS guideline explains an assessment should be carried out to consider if it ‘is necessary to prevent harm to the person and is a proportionate response to the likelihood and seriousness of that harm’.

17. Our adviser explained this is a last resort. In a case like Mr B’s, nurses should try to identify any triggers to agitation so this can be managed or treated. We will take Mr B’s dementia into account as we consider Mrs B’s specific complaints.

Skin care

18. The Trust’s skin care policy explains that for patients with cellulitis, ‘basic wound care can be managed on ward or department however consider referral to the Tissue Viability Specialist Team if wounds are/or complex or do not show improvement’. Our adviser explained that as Mr B was receiving weekly dressings for his legs, nurses should have continued this in hospital.

19. The Trust’s pressure ulcer guideline says some patients are predisposed to pressure ulcers (skin damage caused by friction or pressure) due to existing conditions or environmental factors. Mr B was at risk of pressure ulcers due to his age, reduced mobility, dementia and underlying vascular disease (which reduces the flow of blood to the tissues in the body). The pressure ulcer guideline explains:

• visual skin checks should be carried out daily • photographs should be taken of any damage • patients who are at risk of pressure ulcers should be repositioned according to an agreed schedule • those at higher risk or with a history of pressure ulcers should be provided with a replacement mattress (the Trust had several types available to relieve pressure) • all patients at risk of heel pressure ulceration must be provided with devices to provide complete pressure relief to heels.

20. Nurses should categorise each pressure ulcer in adults using a validated classification tool in line with CG179. This categorises the skin on pressure points according to whether it is at risk of deterioration or to the severity of deterioration. The categories range from normal to category 4, which is the worst stage of pressure ulcer where underlying bone, muscle, or other structures are clearly visible. Categorisation should be repeated and documented each time the ulcer is assessed. The Trust used ‘Purpose T’, which our adviser explained is a suitable classification tool.

21. The Trust acknowledged the records in relation to Mr B’s leg dressings are not entirely complete. It said there was a week’s delay in carrying out one weekly dressing change from 3 to 10 January, mostly due to a lack of suitable dressings on the ward. Dressings became available on 9 January, but Mr B declined to have his dressings changed until the following day. The Trust acknowledged dressings are always available from other wards, so a delay for lack of dressings should not have happened. It also noted staff had removed Mr B’s leg dressings by 13 January, but there was no record of when or why.

22. The records show the Trust carried out pressure area checks regularly in line with its pressure ulcer guideline. It classified Mr B’s sacrum (base of the spine) as ‘normal’ on admission, but ‘vulnerable’ from 2 January. On 4 January, shortly before his brief transfer and diagnosis with sepsis, the records document he was in pain and could hardly move. Our adviser explained this increased Mr B’s risk of developing pressure ulcers. As he was now at high risk of developing pressure ulcers, the Trust’s pressure ulcer guidance says it should have provided a replacement mattress at this point. The Trust did not provide an airflow mattress until 16 January.

23. The Trust classified Mr B’s heels as ‘normal’ on admission. On 3 January it changed the classification to ‘vulnerable’. Our adviser explained this meant he was at risk of heel pressure ulceration. In line with the pressure ulcer guideline, the Trust should have given him a device to provide complete pressure relief to his heels from this date. Our adviser explained heel protectors such as Repose boots can be used.

24. Between 26 to 30 January the records say Mr B had Repose boots on, however a different note on 28 January says that foot protection was not applicable. We acknowledge this could have been selected on the electronic record in error. This is over three weeks after the Trust should have started using this device to protect Mr B’s heels. The records show the Trust provided no heel protection after it readmitted him in February, except for on 6 February. A nurse placed a pillow under his legs to offload his heels on this day, but there is no record of a similar action on other days.

25. On 13 January, an occupational therapist and a physiotherapist were reviewing Mr B and noted he had broken pressure ulcers on both heels. A nurse assessed his left heel ulcer as ‘category 2’ (partial thickness skin loss). They staged the right as ‘unstageable’ (full skin loss, but it cannot be determined whether or not underlying structures are exposed, so it could be category 3 or 4). Our adviser explained this is evidence of damage to Mr B’s heels. The Trust’s pressure ulcer guideline nurses says when ulcers are not improving its staff should make a referral to the tissue viability specialist team. Therefore, the Trust should have referred Mr B to the tissue viability nurses (TVNs) on 13 January.

26. The records show nurses checked Mr B’s skin daily, which is in line with the pressure ulcer guideline. However, in the days immediately after the Trust noted pressure ulcers on his heels, the records show his heels were normal or vulnerable. We are not reassured that this sudden improvement is supported by the other available evidence.

27. The NMC Code section 10 stresses that accurate documentation is important as it informs care and clinical decision making. We think the evidence indicates either staff did not complete some checks fully, as they did not see the wounds, or that they did not complete documentation accurately in line with the NMC Code. The Trust transferred Mr B to another hospital the day after staff identified heel damage, and this means his new care team may not have been fully aware of his issues when he arrived.

28. A TVN provided advice on dressing Mr B’s legs in view of his cellulitis shortly after his admission in December. The nurses next referred Mr B to the TVNs was on 16 January, when they assessed him as having a category 3 pressure ulcer on his sacrum. The TVN reviewed Mr B’s sacrum only. They advised nurses what should be used to clean and dress the wound twice weekly, and to regularly reposition him to relieve pressure. A TVN reviewed his sacrum again on 24 January, a day later than planned. They noted no additional concerns about this wound at that time.

29. A TVN did not review Mr B’s heels until 28 January, by which point he had Repose boots in place. This is 15 days after the Trust should have asked a TVN to review his heels. The TVN noted his heels were necrotic (the wounds contained dead tissue). They gave nurses advice on cleaning and dressing his heels and said they should visually assess the wounds every day.

30. A TVN carried out a detailed review of Mr B’s wounds on 4 February, shortly after the Trust readmitted him. They noted his heel pressure ulcers were category 3 and necrotic, but not infected. His sacrum also had a category 3 pressure ulcer. They advised nurses to use a cleaning, dressing, and repositioning regime and to use Repose boots (or even a pillow) to offload pressure from his heels. They recommended an air wave mattress to prevent further pressure area breakdown. Regular TVN reviews then continued until the Trust discharged Mr B.

31. Mr B refused to have nurses check his wounds on 15 January and refused to let them dress his legs on 9 January. He occasionally declined to have staff reposition him due to pain or fatigue. There is evidence in the records the Trust gave him pain relief before it dressed his legs and heels to make him more comfortable, so he was less agitated. Although there are a few occasions when Mr B declined care in connection to his skin and ulcers, the Trust took steps to make this easier. We do not think his dementia was a significant barrier to the Trust providing skin care throughout Mr B’s admissions.

32. In summary, we found failings in the way the Trust cared for Mr B’s skin because it: • did not properly review or properly document the ulcers on his heels at times • did not always dress his legs • should have referred him to the TVN on 13 January, but did not do so until 16 January and did not ask the TVN to review his heels until 28 January, more than two weeks after it should have • should have offloaded his heels with a device (such as Repose boots) from 13 January, but did not do so except for between 26 to 30 January and on 6 February • should have used an air mattress from 4 January, but did not do so until 16 January.

33. Mr B developed gangrene in his heels which we are sorry to learn caused him excruciating pain in his final weeks, despite him taking strong painkillers. This was naturally difficult for Mrs B to witness and she told us she remains traumatised by these events. She believes her husband’s experience could have been avoided, particularly as she told us his GP had managed his existing cellulitis well. We considered what difference a timely air mattress, heel protection, and TVN referral would have made to his outcome. We also considered the impact of better skin checks and regular leg dressing.

34. Mr B was at risk of pressure ulcers, particularly as he had underlying vascular disease. Our adviser explained that even with appropriate assessments and pressure relieving devices, he could still suffer pressure damage. However, it is our view the extent of the damage could have been reduced.

35. The first TVN’s review note reminds staff of the availability of dressings in the emergency department for Mr B’s cellulitic legs. Later TVN notes stress the importance of offloading the pressure on his heels. The TVNs recommended appropriate pressure relieving devices as soon as they were aware of the damage to Mr B’s sacrum and hells. Therefore a timely TVN referral would likely have prompted timely use of heel protecting devices as well as an air mattress.

36. It is harder to say what the impact of better leg dressings would have been. The purpose of cleaning and dressing Mr B’s cellulitis was to manage the infection, and this did not always happen as it should. The records show clinicians’ main concerns with his skin were his heels and his sacral sore, which they suspected had become infected by the time of his final admission. Nonetheless, Mr B would have been more comfortable if the Trust had dressed his legs when it should.

37. Even with optimal care, Mr B unfortunately had a risk of developing pressure ulcers and gangrene. If the failings we have identified did not happen, the Trust could have minimised the risk by providing an airflow mattress and heel protectors much sooner than it did. Mr B missed an opportunity for a better outcome. He may not have developed pressure ulcers or they may have been less severe, and he may not have developed gangrene, or it may not have developed as soon as it did. This would also represent a missed opportunity to live his final weeks with less of the associated pain. At the very least, Mr B would likely have been more comfortable if the Trust had given him appropriate pressure offloading devices and dressings at the right time. Mrs B believed the Trust could have done more to prevent the damage to her husband’s skin and we understand it may cause her distress that we agree.

38. Our Principles for Remedy say that where or poor service has led to injustice, public bodies should try to offer a remedy that returns the person affected to the position they would have been in otherwise. If that is not possible, the remedy should compensate them appropriately. They should ensure the complainant receives an assurance that lessons have been learnt and an explanation of changes made to prevent maladministration or poor service being repeated.

39. It is not possible to change what happened, so Mrs B would like the Trust to make sure the failings we have found do not happen again.

40. As mentioned above, the Trust acknowledged some delays in dressing Mr B’s legs. It said was sorry he developed gangrene despite its care. It also shared feedback about dressings with nursing staff for reflection and to remind them about the availability of dressings. However, it did not identify any failings in the way it managed his pressure areas and the risk he would develop pressure ulcers. This means it did not identify any learning it could take from this care or apologise for the impact it may have had. Therefore, this does not go far enough to put things right for Mrs B in line with our Principles for Remedy.

Hygiene and repositioning

41. Mr B’s wife supported him with his hygiene at home as he was unable to manage everything himself. CG138 1.2.9 says ‘ensure that the patient's personal needs (for example, relating to continence, personal hygiene and comfort) are regularly reviewed and addressed. Regularly ask patients who are unable to manage their personal needs what help they need. Address their needs at the time of asking and ensure maximum privacy’. In line with this the Trust should have assisted Mr B with his personal care, particularly as he needed increasing support as he became more unwell.

42. Mrs B told us that sometimes her husband’s incontinence pads obviously needed changing when she arrived, and she did not know how long this had been the case.

43. When considering the records alone, we can see regular references to nursing staff giving assistance to Mr B with his hygiene and mouthcare. The records were fully completed in this respect. We can see that he usually required two carers to support him with washing and with changing his incontinence pads.

44. Mr B also needed support to reposition himself in bed or move to his chair. Towards the end of his admission, he became more frail and needed to stay in bed. Initially, he was able to reposition himself in bed or with only moderate assistance. Our adviser considered there were regular and sufficient references in the records to repositioning taking account of his pain and fatigue.

45. As Mr B had dementia, staff needed to use strategies to try and get him to cooperate with care. There are frequent references in the records to staff giving encouragement to him with eating, drinking, and moving. For example, the physiotherapist noted on 21 January he was ‘less willing to engage today but did agree with some encouragement’. This was not always successful. On 15 January ‘lots of encouragement [was] provided but [Mr B] reported he was comfortable and would not get out of bed’. Taking account of what our adviser said staff should do short restraining a person with dementia, this encouragement is in line with what we would expect to see the Trust doing.

46. Mr B became incontinent of urine and faeces by the end of his admissions, with occasions of diarrhoea. This means he would suddenly and unexpectedly need assistance with his hygiene at times. It is not possible to see from records how long Mr B was in a dirty incontinence pad, and nor would the Trust necessarily know how long it was dirty for. We can, however, see staff provided regular assistance with hygiene. This is in line with CG138 because staff regularly reviewed and addressed his needs.

47. There are also frequent references to mouthcare throughout the records, which we would expect in line with CG138. Throughout the whole period there is only one record of Mr B declining mouthcare. Otherwise, staff recorded he was independent with mouthcare or that a nurse had assisted him with mouthcare.

48. Mrs B shared two photos of her husband which she said were taken towards the end of his stay in hospital. She said they showed how poor the condition of his mouth had become which he was an inpatient. There is clearly a lot of old debris or plaque on his teeth, more than could be accounted for by one occasion of him declining recent mouthcare. We cannot know from the photos what his mouth looked like throughout his admission, or how it looked when he was admitted. However, if Mr B had been in hospital for some time when the photos were taken, the Trust had not provided adequate mouthcare for at least a short period, as the level of debris and plaque would be much less.

49. Therefore the Trust did not always carry out mouthcare effectively, or Mr B was not always independent with this as the records said. To this limited extent, we have found failings in the way the Trust supported Mr B with his hygiene.

50. Not having a clean mouth would have affected Mr B’s dignity and comfort, and it was distressing for Mrs B to witness.

51. The Trust accepted that mouthcare had been inadequate and it said it was sorry. It arranged for staff in that area to undertake training. We think that goes far enough to address this matter in line with our Principles for Remedy because the Trust has acknowledged what went wrong and apologised for it. The records show that staff regularly considered mouthcare – the evidence suggests the problem was the standard of mouthcare provided. This means that training would be an appropriate way for Trust staff to learn from this aspect of the complaint. Therefore, we are not going to recommend anything further in relation to this part of Mrs B’s complaint.

1. We are sorry to learn Mr B developed gangrene while he was in hospital and this caused him excruciating pain in his final weeks. Gangrene is a condition in which blood stops flowing to affected tissue which then dies. This was understandably very distressing for his wife, Mrs B, to witness.

2. We have found failings in the way the Trust cared for Mr B’s skin. This means he missed an opportunity to avoid developing painful gangrene in his final weeks. The Trust has already acknowledged some of the failings we have found but it needs to do more to put the impact of them right. We have also found failings in the way the Trust managed Mr B’s mouthcare. It has already done enough to put this right. Therefore we have decided to partly uphold Mrs B’s complaint.

3. We are making recommendations based on what we have found.

52. We make recommendations in line with our Principles for Remedy which are reflected in the NHS Complaint Standards. These say organisations should identify instances where things have gone wrong, take responsibility for these and find ways to put things right for those involved. They should learn from complaints to improve services.

53. We have identified failings in relation to skin care in connection with review and documentation of pressure ulcers, dressings, involvement of the TVN, and use of medical devices to reduce the risk of pressure ulcers developing. We consider this led to a loss of opportunity for Mr B to avoid developing painful gangrene and to be more comfortable in his final weeks.

54. With that in mind, we recommend that following this final report the Trust: • writes to the Mrs B within four weeks to acknowledge the failings we identified in paragraph 32 and apologise for the impact we found in paragraph 37 • explains what action it will take, or has taken, to address these failings – it should do this in the form of an action plan which should be shared with us, Mrs B, the Care Quality Commission and NHS England within three months.

55. We will ask the Trust to send us evidence it has completed all of the recommendations we make in the final report. We will check the action plan includes the reason for the failing (where possible), what the organisation does or will do differently in future, who is responsible for each action, the timescale for completion, and how it will be monitored.