Chelsea and Westminster Hospital NHS Foundation Trust

5. Miss D complains about the care and treatment Chelsea and Westminster Hospital NHS Foundation Trust (the Trust) provided to her sister, Ms M. She says during her sister’s hospital admission between July and October 2024, the Trust failed to:

• prescribe appropriate pain relief • take appropriate steps to prevent falls • adequately manage her wound care and infection

6. Miss D says the Trust’s poor care and treatment led to her sister becoming increasingly unwell and contributed to her sad death. This caused significant distress to Miss D and her family.

7. Miss D would like an apology, service improvements and a financial remedy.

8. Ms M was in her fifties and had a history of chronic leg swelling, a chronic leg ulcer and hypertension (high blood pressure).

9. On 18 July 2024 Ms M attended the Emergency Department (ED) at the Trust because of leg swelling. On examination, clinicians found she had a very large ulcer on her left leg with significant slough (dead or non-viable tissue) and blood. The impression was left leg cellulitis (skin infection) with deep tissue involvement. The Trust admitted Ms M under the care of the medical team for further investigations and treatment.

10. During Ms M’s hospital admission, the tissue viability nurses (TVN) regularly reviewed her. On 30 August, Ms M’s condition worsened, and she was transferred to the intensive therapy unit (ITU) for further monitoring.

11. On 8 October, Ms M was transferred to the care of the plastics team at a different hospital. She had several wound debridement procedures, which is where dead or infected tissue is removed from a wound to promote healing.

12. On 24 October Ms M’s clinical condition rapidly deteriorated and a CT scan showed she had a severe hypoxic brain injury which was not survivable. Clinicians decided to withdraw treatment and Ms M very sadly died.

Wound care/ infection management

16. Miss D says the Trust failed to properly care for her sister’s wounds and treat her infection during her admission. The Trust says the tissue viability team regularly reviewed Ms M. It acknowledged there was an occasion on 26 September when nurses used the wrong wound dressing as they did not review the updated care plan.

17. NICE guidance NG253 on suspected sepsis in people aged 16 or over says:

1.8.1 For people in hospital who have suspected infections, start looking for the source of infection and take microbiological and blood samples before giving an antimicrobial

1.8.2For people aged 16 or over who are at high risk of severe illness or death from sepsis:

•arrange for a clinician with core competencies in the care of acutely ill patients (FY2 level or above) to urgently assess the person's condition and think about alternative diagnoses to sepsis •carry out a venous blood test, including for: • blood gas, including glucose and lactate measurement • blood culture • full blood count • C-reactive protein • urea and electrolytes • creatinine • liver function tests • a clotting screen •give antibiotics in line with recommendation 1.8.3 and the recommendations on choice of antibiotic therapy •refer to the senior clinical decision maker as soon as possible

18. NICE guidance NG152 on Leg ulcer infection: antimicrobial prescribing says:

1.1.3 Only offer an antibiotic for adults with a leg ulcer when there are symptoms or signs of infection (for example, redness or swelling spreading beyond the ulcer, localised warmth, increased pain or fever). Antibiotic use would be guided by:

• the severity of symptoms or signs • the risk of developing complications • previous antibiotic use.

19. The National Wound Care Strategy Programme on lower limb wounds says:

• understand the wound healing process and other factors which can affect healing • be able to recognise clinical signs and symptoms of wound deterioration and manage them effectively.

• be able to recommend and carry out agreed wound management techniques and therapies within the scope of practice.

• make timely and appropriate wound management referrals • be able to carry out microbiological wound sampling and ensure that the results are interpreted by an appropriate member of the multi-disciplinary team • work collaboratively with members of the multi-disciplinary team to maximise patient concordance.

20. On 18 July 2024, Ms M was admitted to the Trust via the ED. She had a six-month history of a chronic venous ulcer on her lower left leg, and this was worsening. A venous leg ulcer is a long-lasting (chronic) sore usually caused by high pressure in the veins and can develop after a minor injury. Underlying causes include immobility, obesity, previous DVT or varicose veins.

21. Ms M said she had experienced a prolonged period of low mood and poor self-care and had not been eating or drinking well after her mother’s death four years previously. Ms M had also become limited by lymphoedema which is a chronic (long-term) condition that causes swelling in the body's tissues.  Ms M reported she now slept in a chair at home and was unable to lie flat due to breathing issues. She had not sought help for her leg wounds until her sister insisted she attend hospital. Ms M also had several poor prognostic factors, as she was malnourished, anaemic (low iron), obese and deconditioned. Deconditioning is the decline in physical and mental functioning due to inactivity or bed rest.

22. Clinicians were initially concerned about possible sepsis because of the appearance of the leg ulcer. They took blood cultures and wound swabs, as well as completing more routine blood tests. This management was in line with section 1.8 of the NICE guidance on suspected sepsis.

23. Our physician adviser tells us the initial results did not show any evidence of sepsis, and her blood pressure and other observations were stable at this time. Clinicians therefore treated Ms M as having a local skin and soft tissue infection in a mixed ulcer and appropriately prescribed antibiotics. The team followed the antimicrobial guidance set in the NICE guidance on leg ulcer infection (NG152), choosing the second line antibiotic as directed by local microbiology team.

24. On 19 July, Ms M had an X-ray of her left lower leg which showed periosteal changes (bone covering membrane), indicating this was very deep infection. She then had a CT angiography of her lower limbs which excluded artery blood vessel blockage as a cause of the ulcer. Ms M also had an MRI of her left leg which showed myositis (muscle inflammation), likely due to infection. Clinicians prescribed vancomycin, which is an antibiotic used to treat serious bacterial infections, on the advice of the microbiology team.

25. Our physician adviser says the Trust provided a good standard of care for Ms M’s initial presentation. It initially managed her as having suspected sepsis and considered the possibility of more serious infections and blood vessel problems. Clinicians carried out timely and appropriate investigations in accordance with the NICE guidelines on both sepsis and prescribing for leg ulcers. The antibiotic prescriptions were also appropriate and in line with guidance.

26. The TVN reviewed Ms M on 22 July and advised the use of an antimicrobial dressing to reduce the bacteria load, a blood glucose check and podiatry referral. The TVN also advised the wound should be redressed every three days. From the notes, we can see the nursing staff followed the National Wound Care Strategy Programme guidance by regularly assessing and redressing Ms M’s wounds and reassuring her when necessary. There was regular TVN input and there were also several occasions when nursing staff agreed to change Ms M’s dressing earlier than required due to her distress.

27. Clinicians prescribed Ms M with further antibiotics (clindamycin and teicoplanin) on 8 and 14 August following advice from the microbiology team. On 19 August, the vascular team reviewed her and requested a duplex scan to ensure there were no arterial issues.

28. On 16 August, clinicians noted Ms M had worsening kidney function. By 30 August, the notes show she was generally less well. She had reduced urine output, she was drowsy and she had worsening renal function and low blood pressure. The treating clinicians discussed Ms M’s management with the renal team and decided to transfer to the ITU for further monitoring and treatment for sepsis. Clinicians acted in line with paragraph 1.8.2 of the NICE sepsis guidance and carried out the recommended tests and prescribed antibiotics according to microbiology guidance. Ms M recovered from this episode but was debilitated by it, with therapists commenting on her reduced functional status.

29. Ms M had also suffered relatively minor trauma to her right thigh after falling on 30 August. Our physician adviser tells us the ulcer that subsequently developed from this shows a very severe degree of skin breakdown, suggesting there was extreme skin fragility.

30. On 8 October, Ms M was transferred to the care of the plastics team at a different hospital. She had several wound debridement procedures, which is where dead or infected tissue is removed from a wound to promote healing. Our physician adviser says this was appropriate because without removing the infected and dead tissue, the ulcers would not heal.

31. Even after having these procedures, it was clear that the ulcers would not heal, likely due to the underlying issues. Ms M’s leg ulcers were very severe and there was an exceptionally high level of skin breakdown. The clinical photographs demonstrate full thickness infected leg ulcers, covering 8-10% of her body surface area. She was vulnerable, with a combination of poor prognostic factors including malnutrition, anaemia, insulin resistance and deconditioning. Our physician adviser says taking all of this into account, sadly her prognosis was poor. Very sadly, Ms M deteriorated during this admission and developed a metabolic encephalopathy with raised brain pressure which ultimately led to her death. Metabolic encephalopathy describes a brain dysfunction resulting from imbalances in the body’s chemical processes. It is a consequence of other underlying medical conditions. Our physician adviser tells us sadly there is no evidence that this could have been prevented. This is because the deterioration occurred despite the fact that Mrs C Hearne was already receiving appropriate medical care.

32. Overall, we consider the Trust acted in line with guidelines when managing Ms M’s wound care and infection. The Trust has acknowledged on 26 September nursing staff used the wrong dressing as they had not reviewed the updated TVN care plan. We appreciate this would have been worrying for Miss D to discover. Miss D also maintains there were other occasions when she went to see her sister and her wounds were not properly dressed. This was a long period of over three months. Reviewing a period of every aspect of nursing care over this length of time will inevitably result in the identification of examples of situations where care could have been improved, or where a different approach should have been taken. We have considered the period as a whole, looking at the overall picture from the recorded evidence, and consider the Trust provided good wound care in line with guidelines.

33. We are truly sorry to hear about Ms M’s death and appreciate it has been an incredibly difficult and distressing time for Miss D and her family. We have seen the Trust’s management of Ms M’s wounds and infection were appropriate and in line with guidance and we do not uphold this part of the complaint.

34. Pain management

35. Miss D says the Trust failed to properly manage her sister’s pain throughout her hospital admission. The Trust says the pain management team reviewed Ms M and ward staff followed their recommendations.

36. Pain management generally follows the World Health Organisation (WHO) analgesic ladder, with local adaptations. The key principles in analgesic (pain relief) prescribing are ‘by the clock’ (regular prescribing), ‘by the mouth’ (oral whenever possible) and ‘by the ladder’ (increase in a stepwise way, starting at the lowest dose and increasing as the patient needs).

37. Paragraph 16c of GMC guidance says doctors should ‘take all possible steps to alleviate pain and distress whether or not a cure may be possible’.

38. As noted above, Ms M had large deep infected venous/infective leg ulcers. Our physician adviser explains venous ulcers tend to be less painful than arterial ulcers (caused by poor blood flow) but are still problematic, particularly if they become infected or wet and when dressings are being changed. Over 50% of patients with leg ulcers also have neuropathic (nerve pain) symptoms, such as burning, shooting, or tingling sensations, likely due to nerve impairment from lack of blood supply. Our physician adviser says Ms M’s pain from her ulcers was therefore likely to be moderate to severe.

39. Ms M’s pain management was more challenging because her pain was exacerbated by dressings being done and by any type of care. It was also more challenging because of her acute and chronic kidney failure, as some pain killers are metabolised (processed) through the kidneys and must be used with caution if there is kidney impairment as it can lead to further kidney damage.

40. Our physician adviser tells us a key element in pain management is to monitor pain regularly and explore the nature of the pain. Pain should be checked at regular intervals, such as during observation rounds and medical ward rounds. There is some evidence of pain monitoring in the notes, but it does not appear to be consistent. Ms M regularly reported she was experiencing pain.

41. From the notes, we can see clinicians gave Ms M 142 doses of paracetamol during her 98-day admission. She mostly received this regularly, but it was not always consistent throughout. Clinicians had also prescribed amitriptyline for Ms M to take at night from 17 until 25 September, which is a medication recommended in NICE guideline CG173 to treat nerve pain. It is not clear from the notes why clinicians stopped prescribing this. Ms M also received 81 doses of 2.5mg of oxycodone (a low dose), on an ‘as required’ basis. Oxycodone is an opioid medication used to for moderate to severe pain. Clinicians did not increase the dose at any point, despite the notes showing Ms M continued to suffer severe pain and crying out with this. This is not in line with the WHO principles on titrating medications according to need or the GMC guidance on taking all possible steps to alleviate pain.

42. Based on the evidence we have considered, we have found the Trust failed to appropriately prioritise and manage Ms M’s pain management in line with guidance throughout this admission. We recognise it would have been extremely distressing for Miss D to witness her sister in so much pain, and we are very sorry to hear about the impact this had. The Trust has not acknowledged anything went wrong here so it has not taken any steps to remedy this. We have therefore made recommendations at the end of this report to put this right.

Falls

43. Miss D says the Trust failed to take appropriate action to prevent her sister falling during her admission. The Trust says the falls risk assessment did not identify she had a significant risk of falling and it provided nonslip socks for safety.

44. In accordance with NICE guidance of falls (CG161), the Trust should have completed a comprehensive falls risk assessment when Ms M was admitted to hospital. If she was at risk, staff should put interventions in place to reduce the risk of her falling. Ms M should also have been encouraged to participate in actions that would prevent her falling such as use of call bell and mobility equipment. She should have also been provided with education and advice around the risk of and preventing falls.

45. From the notes we can see nursing staff completed a falls risk assessment when Ms M was admitted in line with the NICE guidance. This indicated she was not at high risk of falling. Clinicians deemed she had capacity and was able to mobilise independently with a Zimmer frame, though only short distances because of her leg swelling. Ms M scored a one on the Trust’s enhanced observation scoring (EOS) assessment, which meant that she did not require any increased supervision.

46. Nurses documented within Ms M’s admission assessment that all safe mobility interventions were activated, which included ensuring:

• the bed space and bay was hazard free • mobility support items were available • all personal items were within reach • the call bell and night light were within reach • anti slip socks were provided

47. All of these actions are in line with NICE guideline CG161 and indicate nursing staff took appropriate action to assess Ms M’s falls risk and attempt to prevent her falling.

48. On 17 August, the notes show Ms M fell after mobilising to the toilet independently. She did not sustain any injuries. In line with the NICE guidance, this prompted a repeat risk assessment, using the EOS system. Ms M scored a three, which meant that she was at risk of falls but did not require an increased level of observation. Later in the day, staff documented Ms M had capacity and was able to call for help if she required assistance, her call bell was in reach and that she was wearing anti slip socks. This shows interventions were in place to try and minimise the risk of Ms M having a further fall.

49. On 30 August, the notes say Ms M had fallen by slipping out of a recliner chair. The nurse looking after her had documented earlier in the day she was concerned about Ms M’s drowsiness and asked her to move to the bed for safety. Unfortunately, Ms M declined to do so. Our nursing adviser tells us the nurse had to respect Ms M’s wishes not to move as she still had capacity at that point.

50. Due to the change in clinical condition, a further EOS should have been completed in line with NICE guidance. We cannot see any evidence this happened. Our nursing adviser tells us Ms M would have scored a four at this point because of her drowsiness. This would have resulted in an increased level of supervision, with a member of staff based in the bay to observe her at all times. The fall was unwitnessed by nursing staff, however another patient reported Ms M fell forward whilst asleep. This fall resulted in a haematoma (severe bruise within the soft tissues) to the inside of her thigh, which as noted in the section above later massively deteriorated.

51. We have found the Trust undertook appropriate risk assessments and took appropriate actions in preventing Ms M from falling for the majority of her admission. The only exception to this is on 30 August when Ms M slipped out of her chair. If staff had done a repeat EOS, Ms M would possibly have been supervised by a bay nurse at the time she fell. Whilst we recognise this could have possibly reduced the risk of falls, our nursing adviser explains this does not mean the fall could have been prevented as the nurse would not necessarily have reached Ms M in time to stop her slipping from the chair. Based on the other patient’s account, there does not appear to have been warning she was about to fall. We therefore cannot say this fall or the injury that stemmed from it was avoidable. We recognise it will be distressing for Miss D to learn there was a failure to carry out a further EOS when her sister’s clinical condition changed. Again, the Trust has not acknowledged anything went wrong here so it has not taken any steps to remedy this. We have therefore made recommendations at the end of this report to put this right.

1. We have decided to partly uphold this complaint. We are truly sorry to hear about Miss D’s concerns and recognise this has been a very difficult time for her and her family.

2. We consider overall, the Trust appropriately managed Ms M’s wound care and infection in line with the relevant guidelines.

3. We have found the Trust failed to manage Ms M’s pain in line with guidelines. We have seen whilst the Trust largely acted in line with guidance when assessing Ms M’s falls risk, there was an occasion when nursing staff failed to reassess the risk when her clinical condition changed, and she fell shortly afterwards. Whilst we cannot say the fall was avoidable, we recognise these failings meant it was likely Ms M experienced additional pain and this caused further distress to the family at an already incredibly upsetting time.

4. We have made recommendations based on what we have seen. We recommend the Trust apologises to Miss D for the impact the failings have had and pay her a financial remedy of £750. We also recommend the Trust produces an action plan to show what it will do to prevent a recurrence of the failings we have identified.

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 expect organisations to take action to compensate people appropriately if they cannot return them to the position they would have been in if the poor service had not occurred. In some cases, a financial remedy will be required. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.

54. We have identified failings in relation to pain management and reassessing falls risk when the clinical condition changes. Whilst we cannot see this was linked to her death, we consider this caused additional distress to Miss D during an already very upsetting period.

55. With that in mind, we recommend that following this final report the organisation:

• writes to the complainant by 29 August 2026 to acknowledge the failings we have identified and apologise for the impact of the failings we have identified • pays the complainant £750 by 29 August 2026 in recognition of the distress caused by the failings we have identified • explains what action it will take, or has taken, to address these failings by 29 October 2026. It should do this in the form of an action plan which should be shared with us and the complainant.

56. The organisation should send us evidence it has completed all of the recommendations we have made. 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.