Bolton NHS Foundation Trust

4. Mrs A complains about the care provided to her husband, Mr B, by Manchester University NHS Foundation Trust (MUT) from 2 to 14 July 2022 and from 14 July to 22 August 2022. Specifically:

• there were delays during Mr B’s first hospital admission in providing appropriate treatment for the sepsis arthritis in his right knee and a lack of adequate pain relief • Healthcare Assistant’s (HCA’s) were rude shouting at Mr B when he was in hospital.

5. Mrs A says the unexpected death of her husband has deeply affected her to the point that she cannot exist without him. Mr B had several hospital admissions in 2022 due to pain in his right knee. He sadly died on 8 January 2023 after an 11-day hospital admission. Mrs A says that if her husband’s leg had been amputated, it would have saved his life. Mrs A’s eldest daughter also sadly died due to cancer just a few weeks before her husband, so she suffered a tragic double family bereavement in a short period of time.

6. As an outcome, Mrs A wants a financial remedy from MUT to reimburse her for transport costs when she had to visit her husband in hospital.

7. Mrs A complains about the care provided to her husband, Mr B, by Bolton NHS Foundation Trust (BFT) from 8 to 30 September 2022 and from 29 December 2022 to 8 January 2023. Specifically:

• Mrs A says that Mr B should have had his leg amputated when he was in hospital • why was a Do Not Attempt Resuscitation (DNAR) order put in place for Mr B during his second admission.

8. Mrs A says the unexpected death of her husband has deeply affected her to the point that she cannot exist without him. Mr B had several hospital admissions in 2022 due to pain in his right knee. He sadly died on 8 January 2023 after an 11-day hospital admission. Mrs A says that if her husband’s leg had been amputated, it would have saved his life. Mrs A’s eldest daughter also sadly died due to cancer just a few weeks before her husband, so she suffered a tragic double family bereavement in a short period of time.

9. As an outcome, Mrs A wants a financial remedy from BFT to reimburse her for transport costs when she had to visit her husband in hospital.

10. Please note that we have not included all the background to the complaint in this report as all parties already know this information. We have included the information outlined in this section to put the complaint into context.

11. Mr B was in his 70s and had type 2 diabetes. All his toes had been amputated, and this affected his balance. He used a walker to mobilise but had bumped into a storage heater at home which caused an injury in his right knee. In June 2022, Mr B's GP prescribed antibiotics for right knee sepsis arthritis.

12. Mr B was admitted to hospital on 2 July 2022 due to sepsis arthritis in his right knee. Mr B was diagnosed with Covid-19 on 4 July 2022. He was treated for this and his knee condition over the next few days. On 14 July 2022, Mr B was transferred to another hospital. He was diagnosed with an infection called pseudomonas aeruginosa. Mr B had a washout of his right knee joint on 15 July 2022. He was treated with Clindamycin and Meropenem whilst an inpatient. Mr B was discharged on 22 August 2022.

13. Mr B was admitted to hospital on 8 September 202 from the emergency department with increasing knee pain. On 9 September 2022, Mr B had another washout of his right knee joint. The infection was treated with intravenous meropenem. Mr B was discharged from hospital on 30 September 2022 and completed his course of antibiotics on 4 November 2022.

14. On 29 December 2022, Mr B was admitted to hospital from the emergency department as the condition of his knee was deteriorating. MRI tests found pseudomonas aeruginosa present, so Mr B was started on IV Meropenem and oral Ciprofloxacin. Mr B was reviewed as an emergency on 4 January 2023 due a suspected stroke. CT and MRI scans show no signs of stroke, but Mr B is thought to have had a seizure. This prompted a resuscitation discussion with Mrs A.

15. Mr B was prescribed Tobramycin on 5 January 2023 and Fosfomycin on 7 January 2023. Mrs A felt that her husband’s antibiotics were no longer effective. Unfortunately, Mr B’s organs began to shut down at this point, and he sadly died on 8 January 2023.

Care at MUT

20. Mrs A says there were delays during Mr B’s first hospital admission in providing appropriate treatment for the sepsis arthritis in his right knee and a lack of adequate pain relief.

21. Firstly, we note that MUT has already acknowledged in its complaint response that Mr B having to wait 13 days (from 2 July 2022) for a washout procedure on his right knee was an unacceptable delay. Our adviser says the orthopaedic team decided on 7 July 2022 that Mr B needed a washout procedure, but he still did not get this treatment until 15 July 2022. This must have been frustrating for Mr B and distressing for Mrs A to witness.

22. The BOAST guidance states:

‘Native joint infections should be treated according to standards outlined in the BOAST for the acute management of periprosthetic joint infection2.

‘Consultant orthopaedic review of the systemically well/stable patient should occur within 48 hours of presentation and the planned next step for management determined and recorded with onward referral as appropriate’.

23. Therefore, in accordance with the BOAST guidance, our adviser says that Mr B should have been offered a washout procedure of his right knee within 48 hours of admission to hospital as this was the next step to appropriately manage his condition.

24. The GMC Good medical practice guidelines states:

‘In providing clinical care, you must: promptly provide (or arrange) suitable advice, investigation or treatment where necessary.’

25. Our adviser says Mr B had been diagnosed with Covid at the time. The circumstances of interhospital transfer in a Covid positive patient during a pandemic is clearly exceptional, but notwithstanding, in a high-risk patient this level of delay is significant.

26. Therefore, we consider the delay in Mr B being offered a washout procedure is a failing by MUT contrary to the BOAST and GMC guidance.

27. As for the impact of this delay, our adviser says that although Mr B’s washout procedure on 15 July 2022 helped to clear his knee of infection, the relevant organism (that caused the infection) was not totally eradicated after this procedure. It is an organism known to form a biofilm in the body that it uses to hide from the body’s immune system, this is likely why the infection reoccurred later in the year.

28. It could be argued that if Mr B had his washout sooner, the infection could have been cleared reducing the chance of further flare ups, but our adviser says there is insufficient evidence to say that the organism formed due to a delay with his care. We do not know when it started. It could have been when Mr B was in hospital or much earlier, and his immune system and biological reserve is reduced irrespectively. There is insufficient evidence to say either way. As such, the impact is limited to some inconvenience for Mr B while he waited for treatment.

29. We note MUT apologised for this delay. It said that during July and August 2022, there were significant pressures for beds due to high patient demand. The main reason for this was pressure caused by the Covid pandemic. As we have said, Mr B had Covid at the time which added complexity and delay to his transfer as appropriate Covid guidelines had to be followed.

30. In summary, although we consider there was a failing by MUT due to the significant delay in Mr B being offered a washout procedure, it has apologised and explained the reasons for this. It was an unprecedented situation with Covid at the time and there is insufficient evidence for us to say that the delay had a negative clinical impact on Mr B. This was unfortunate for Mr B, but we consider the inconvenience that he suffered due to the delay in his treatment is rectified by MUT’s apology and explanation. As such, there is no further action for us to take regarding this matter.

31. As for Mr B’s pain relief medication during his hospital admission from 2 to 14 July 2022, the NICE guidance on managing suspected sepsis states:

‘Paracetamol should be considered for fever management (though emphasising that it is not a treatment and should never delay antibiotic treatment) and that pain assessments should frequently, and appropriately monitor pain relief, for example 4 hourly in pregnant patients with sepsis’.

32. As there is evidence in the records that Mr B was given Paracetamol during this admission, our adviser says he was provided with appropriate pain relief medication for his condition (sepsis arthritis) in accordance with the NICE guidance. Although it is not entirely clear from the records how well Mr B was supported by MUT in terms of managing his pain during this admission, it is documented that he was prescribed appropriate, additional pain relief.

33. Mrs A says Healthcare Assistant’s (HCA’s) were rude shouting at Mr B when he was in hospital.

34. We can see from Mrs A’s complaint to MUT that she raises concerns about HCA’s being rude to her and Mr B when he was in hospital. This complaint is undated, but Mrs A says she sent it to MUT on 1 March 2023.

35. We note that when MUT wrote to Mrs A on 17 May 2024, it agreed to investigate three specific issues. However, none of these issues were about HCA’s being rude to her or Mr B when he was in hospital. Therefore, when MUT completed its investigation and came back to Mrs A with a substantive response on 18 June 2024, this issue had not been addressed.

36. We are sorry to hear that Mrs A and her husband experienced some rudeness from HCA’s when Mr B was in hospital. This must have been upsetting for both at an already difficult time when Mr B was unwell. This compelled Mrs A to include these concerns in her complaint, but MUT has not addressed them in its responses.

37. It is unclear why MUT has not addressed this issue in its response, but we consider there was an opportunity for Mrs A to confirm this issue as part of the investigation when MUT wrote to her on 17 May 2024 about which issues it intended to look at. If Mrs A was dissatisfied with the three issues put forward for investigation by MUT, she should have let them know about this at the time and reiterated her concerns about the HCA’s. There is no evidence Mrs A did this.

38. There is an argument that MUT should have identified this issue from Mrs A’s complaint and put it forward for investigation. The fact that it did not is regrettable, but we maintain there was an opportunity for Mrs A to rectify this omission which was not taken. We consider the main reason for MUT contacting her on 17 May 2024 was to confirm which issues it was investigating.

39. We were not present to witness HCA’s being rude to Mrs A or her husband when he was in hospital. While we acknowledge Mrs A’s recollection of this and the upset it caused her and her husband, the lack of response from MUT means there is insufficient evidence for us to uphold this part of Mrs A’s complaint.

Care at BFT

40. Mrs A says that Mr B should have had his leg amputated when he was in hospital.

41. We have considered Mr B’s medical records from when he was in hospital at BFT from 8 to 30 September 2022 and from 29 December 2022 to 8 January 2023, with support from our adviser.

42. Based on the available evidence, our adviser says that although there is some evidence that amputation was discussed with Mr B latterly during his final hospital admission, it was never a reasonable treatment option. Our adviser says that amputation of a limb is reserved as a last resort treatment option. As late as December 2022, an MRI scan showed that Mr B’s infection was confined to his knee joint. It was only in January 2023 that his condition became life-threatening.

43. We have not seen anything documented in the records detailing Mr B’s views on the possibility of amputating his leg, but after suffering a suspected stroke and then seizures in January 2023, his organs began to shut down, and he sadly died on 8 January 2023. Therefore, even if we took the view that amputation became a possibility in January 2023, other clinical events overtook this last resort procedure being considered any further. It is also important to remember that amputation carries a large physiological and mental burden to a patient. The risks are significant and an amputation itself can be life threatening.

44. Mrs A says she is unsure why a Do Not Attempt Resuscitation (DNAR) order was put in place for Mr B during his second hospital admission.

45. Our adviser says that Mr B was a diabetic who struggled with his mobility. He had been receiving treatment for sepsis arthritis in his knee for several months. Despite this, the condition of his knee began to deteriorate in December 2022 and by January 2023, clinicians were concerned about Mr B’s reported confusion, low blood sugar, as well as a suspected stroke and seizures. There had been an overall deterioration in Mr B’s health. As such, our adviser says it was appropriate for a DNAR order to be discussed which it was.

46. The GMC professional standards on assessing capacity state:

‘If you believe a patient may lack capacity to make a decision, you must assess their capacity using the test set out in the relevant legislation, taking account of the advice in the relevant guidance. If you find it difficult to judge whether a patient has capacity to make a decision, you should seek support from someone who knows the patient well, for example, another member of the healthcare team or someone close to the patient.’

The GMC guidance on cardiopulmonary resuscitation states:

‘If a patient is admitted to hospital acutely unwell or becomes clinically unstable in their home or other place of care, and they are at foreseeable risk of cardiac or respiratory arrest, a judgement about the likely success of CPR in restarting breathing and circulation and its benefits, burdens and risks should be made as early as possible’.

‘If a patient lacks capacity to make a decision about future CPR, you must consult those close to the patient as part of the decision-making process. You must approach discussions sensitively and bear in mind that some people may have concerns that some decisions not to attempt CPR might be influenced by poorly informed or unfounded assumptions about the impact of disability or advanced age on the patient’s quality of life. In addition, the views of members of the healthcare team involved in their care may be valuable in assessing the likelihood that CPR would be successful in restoring the patient’s breathing and circulation or whether successful CPR would likely be of overall benefit to them. You must make reasonable efforts to discuss a patient’s CPR status with these healthcare professionals.’

47. If Mr B was suffering from confusion as documented, our adviser says BFT should have carried out a capacity test, in line with GMC professional standards. There is no evidence of this in the records. However, our adviser has also pointed out that DNAR is a best interests decision taken by clinicians. Very sadly, Mr B was now towards the end of his life. With that in mind, as far as DNAR is concerned, our adviser says the records indicate that BFT acted in accordance with the relevant GMC guidance on cardiopulmonary resuscitation, cited above, when providing care to Mr B at this time.

48. This concludes our investigation of the complaint. Please note there are legal restrictions on disclosing information that we give you. This means that you cannot share or make public any information or documents we gave you during our investigation. The legal restrictions do not apply to this final report.

1. We are sorry to hear about the sad circumstances around Mrs A’s complaints to the Ombudsman. We appreciate that Mr B’s tragic death has had a lasting and significant impact on Mrs A and their family.

2. We have seen a failing by Manchester University NHS Foundation Trust regarding the delay in Mr B having a washout procedure on his knee during his hospital admission from 2 to 14 July 2022. However, we consider this has already been appropriately addressed by Manchester University NHS Foundation Trust. We have not seen any other failings by Manchester University NHS Foundation Trust, so there is no further action for us to take. Therefore, we will not uphold the complaint overall.

3. We have not seen any failings regarding the care provided to Mr B by Bolton NHS Foundation Trust. Therefore, we will not uphold the complaint overall.