Chesterfield Royal Hospital NHS Foundation Trust

2. Ms A complains about the impact of the care and treatment provided to her mother, Mrs B, by the Trust in May and June 2024. Ms A says the failings identified by the Trust in its review of her mother's care directly led to her mother contracting the infection which caused her death.

3. Ms A disagrees with the Trust view that her mother died due to the severity of her illness and not as a result of the failings identified in its review of her care.

4. Ms A says the death of her mother and the circumstances under which she died caused her a great deal of distress. She would like the Trust to acknowledge the failings in her mother’s care led to her death. She would also like the Trust to make a financial payment to the family.

5. Mrs B had a medical history of liver disease and liver cirrhosis. She was admitted to hospital on 7 May 2024 with a skin rash and initially treated for suspected vasculitis (a disorder which causes inflammation of the blood vessels). Mrs B remained in hospital for several weeks but her condition deteriorated.

6. Whilst in hospital the Trust diagnosed Mrs B with a bloodstream infection caused by Pseudomonas aeruginosa (a serious bacterial infection). This bacteria was detected by the Trust on 8 June 2024 from tests taken on 3 June 2024. Mrs B sadly died on 9 June 2024.

10. After Mrs B died the Trust carried out a thematic review of patients who have contracted a hospital acquired infection and it also reviewed the care it provided to Mrs B during this admission. The findings were shared with Ms A who then complained to the Trust that the failings it identified in her mother’s care directly led to her contracting the infection which caused her death. The Trust responded to the complaint and said it did not agree the failings led to her infection and Mrs B died as a result of the severity of her underlying illness.

11. The first failing the Trust identified in the care it provided to Mrs B is that there was a lack of information gathered and recorded about her initial treatment and care plans.

Ms A says this indicates appropriate care wasn’t given and her mother got an infection as a result.

12. The Trust said:

‘There appears to be no documentation or clarity on the specific treatments, care plans, or monitoring conducted from her admission date on May 7th until June 3rd, when the infection was detected. Understanding this period is essential to fully evaluate her care and identify any areas where protocols may have been inadequate. Lack of proper documentation of the blood culture procedure and subsequent steps taken.’

13. Pseudomonas aeruginosa bacteraemia is an infection in the bloodstream caused by a bacteria called Pseudomonas aeruginosa. It is often hospital acquired and as the PA risk guidance sets out there are multiple risk factors, some of which Mrs B had. These include prolonged hospitalisation, recent antibiotic treatment for other infections (records indicate Mrs B was treated for pneumonia on admission), pancreatobiliary disease (records indicate Mrs B had both liver cirrhosis and indications of pancreatitis), indwelling catheters, advanced age and wound infections.

14. Our adviser said in light of her condition and the treatment she needed there were multiple risk factors for the development of the infection that ultimately led to Mrs B’s death. Our adviser said the records indicate the Trust had also treated her with steroids for her vasculitis at the start of the admission, which can also depress the immune system and increase the risk of infection.

15. We acknowledge the failings identified by the Trust in the level and quality of information it documented prior to Mrs B’s infection being identified. We have reviewed all of the available records and seen that despite significant gaps in the information and lack of detail in the planning of her care, the records do contain information to show the progression of her condition in the daily care and nursing notes. The records also provide some information on the tests performed and investigations carried out by the Trust, both in the days before the initial signs of infection were identified and in the days that followed.

16. The first indication in the records of possible infection is in the medical ward round of 1 June 2024 when the wound on her abdomen (from the procedure performed by the Trust to drain ascitic fluid on 24 May 2024) is found to smell. The medical ward rounds prior to this do not provide any evidence of earlier indications of infection. Similarly, the daily nursing records provide no evidence of infection until the care interventions on 1 June 2024. The daily wound care charts which were started by the Trust on 23 May 2024 indicate there was no evidence of infection until the assessment on 1 June 2024, which found changes to her abdominal wound consistent with infection.

17. The records we have seen confirm that swabs were taken from Mrs B’s abdominal wound for testing on 28 May 2024 and no sign of bacterial contamination or infection was identified. However after the initial signs of infection were identified during the care interventions on 1 June 2024 a further swab was taken on 3 June 2024 which provided the first positive result for Pseudomonas.

18. We acknowledge the Trust failed to record appropriate initial treatment or care plans during the first few weeks of her admission and we agree with the Trust and Ms A that this has left doubt about the cause of her infection and whether any of the care she received from the Trust contributed to it. This has caused a great deal of frustration and distress for the family. We agree that this is a significant failing, one which the Trust has acknowledged and taken steps to learn from and improve.

19. Having considered all of the information provided to us we are unable to conclude that the failings identified by the Trust in its documentation of Mrs B’s care had the impact claimed in this complaint. We found no evidence which shows there were earlier signs of infection which were missed or not acted upon by the Trust as a result of the failings.

20. The nature and combination of Mrs B’s conditions, and the care she required to treat them, posed a significant risk of infection and we have not found any evidence that would enable us to say she developed the infection because of the failings rather than the risks associated with her condition.

21. The second failing the Trust identified in the care it provided to Mrs B is that it failed to document a clear plan for changing her urinary catheter drainage bag. The Trust said ‘the catheter is not included in the elimination aspect of the care plan. We expect this to be included in this section of the care plan.’

22. Both the PA risk guidance and the PAB study refer to a urinary catheter as a risk factor for Pseudomonas bacteraemia. The records indicate Mrs B had a urinary catheter inserted on 27 May 2024 after a scan identified a large amount of urine in her bladder. The records state she was very confused at this time and her confusion continued during the days that followed.

23. The records also indicate Mrs B would pull at her catheter and it had to be replaced on 4 June 2024. The records for 4 June 2024 also state the mitts she wore to prevent her from scratching her skin had faeces on them. Our adviser said the combination of her confused state and pulling the catheter tubing with faeces on her mitts would increase the risk of contamination of the catheter tubing.

24. Our adviser said despite this increased risk there is no evidence in the records of the catheter becoming contaminated. Our adviser said they were unable to identify any evidence in the records of Mrs B’s test results or her symptoms that would suggest a urinary tract infection or contamination of her catheter tube or drainage bag as the cause of the infection she developed.

25. We acknowledge the Trust failed to document a clear plan for changing her urinary catheter drainage bag and we agree this is an aspect of care that the Trust should take steps to improve. However we found no evidence in the records which we can point to that would suggest this failing led to her developing an infection.

26. The third failing the Trust identified in the care it provided to Mrs B is that it failed to document a wound assessment or dressing plan in her medical records. Ms A says this indicates her mother’s wound care was inappropriate and she got an infection as a result. The Trust reviewed this aspect of her care again after it received Ms A’s complaint and it was able to find the records of Mrs B’s wound care.

27. The Trust said:

‘From review of the medical records, we are able to locate wound assessment charts that were commenced on 23 May 2024. The wound assessment chart gives assurance that your mother’s dressings were changed daily up until and including 3 June 2024, apart from a gap of one day on 24 May 2024.

A referral was made to the Tissue Viability Nurse (TVN) on 29 May 2024 for advice on management of the wound, however, due to the dermatology team already being involved and a plan already being in place, it was felt that the TVN team were not able to add anything further. The TVN was happy to re review your mother if the dermatology team requested their input.

From review of the nursing documentation, it is clearly documented when your mother’s dressings were changed, and these changes were at an acceptable frequency. Photographs of the wounds were taken by the medical photographer, which was requested by the nursing staff, which allowed both medical and nursing staff to continue to monitor the wounds for any deterioration and similarly for any improvement. We are satisfied with the management of your mother’s wounds on review of her documentation and discussion with staff.’

28. The records confirm the wound care charts from 23 May to 2 June 2024 report no evidence of infection of the abdominal wound between those dates. There is some discrepancy with the medical ward round entries on 1 and 2 June 2024 which both note the wound had started to produce a smell. The records indicate the wound first showed visual signs of possible infection on 3 June 2024 when the Trust noted the dressing was sodden and the Trust took a swab of the wound for testing.

29. All previous tests had returned negative results for Pseudomonas, however the swab taken on 3 June 2024 grew Pseudomonas. The records indicate the Trust’s microbiology team reported this positive result was either due to possible wound contamination (the presence of microorganisms on the surface of a wound, which is common and often harmless) or infection of the wound (when the bacteria become harmful and multiply, requiring medical intervention).

30. The records indicate the Trust found it extremely difficult to keep Mrs B’s abdominal wound clean due to her symptoms of confusion and disorientation. Examples in the nursing notes to support this include:

• Two sequential nursing entries on 2 June 2024 saying that Mrs B kept taking the dressing off and it had to be replaced multiple times • Nursing entry on 3 June 2024 of scratching and the abdominal dressing required changing multiple times • Nursing entry on 3 June 2024 to say that mittens were being used to prevent damage to the wound from scratching • Nursing entry on 4 June 2024 to say that she was agitated, trying to remove her mitts and her mitts being changed as they had become covered in faeces • Entry on 4 June 2024 from Complex Care Nurse noting her confusion, incontinence and faeces transferring from her hands to her abdominal wounds • Further reviews on 5 and 7 June 2024 from Complex Care Nurse noting ongoing confusion, agitation and attempting to pull at her catheter, nasogastric tube and stomach dressings.

31. This was clearly an extremely difficult time for Mrs B and we appreciate how upsetting this was for her family. It is clear from the information we have seen that her condition and the symptoms she was experiencing were very distressing.

32. Our adviser said the records indicate it was extremely difficult for the Trust’s nursing team to provide care to prevent contamination of Mrs B’s abdominal wound. Our adviser said this may have been a contributory factor to her developing an infection with Pseudomonas, alongside the other individual risk factors Mrs B had which we have mentioned above.

33. However our adviser said Pseudomonas was first identified from a wound swab taken on 3 June 2024 and it is not possible to say that the difficulty the Trust faced when providing wound care to Mrs B led to her developing the infection. Our adviser said this is because she had many other risk factors for developing an infection and there is no evidence we can point to which would exclude the impact the other significant risk factors had.

34. We acknowledge the risk posed by Mrs B’s wound care. However there is no evidence in the records which we can point to that would enable us to say categorically that she developed the infection due to these difficulties and not because of the combination of individual risk factors she had which we have mentioned above or her significant underlying illnesses.

35. Ms A says her mother died as a direct result of the failings the Trust identified in her care. The Trust said:

‘The Pseudomonas aeruginosa was reported on 8 June 2024 at 18:40, from a blood culture that was taken on 3 June 2024. The blood culture results prior to this one were all negative.

It is felt your mother likely had an attack of severe pancreatitis on a background of chronic pancreatitis and liver cirrhosis/failure. She was treated for sepsis although the source of this was never determined from her blood tests, ascitic fluid or urine. Your mother had significant comorbidity and poor physical reserve to cope with the acute physiological demand placed on her body from the inflammatory response from her pancreas and her failing liver. All attempts were made to reverse this process and on reflection, it is very unlikely any other treatment would have successfully done this.

Regrettably, despite various different investigations, we were unable to determine what the source of the infection was that caused your mother’s deterioration. On review of your mother’s care and treatment it is felt that your mother’s wounds were managed appropriately, and the swabs taken of the abdominal wounds did not show any bacteria that would have caused her to become unwell.’

36. Our adviser said the records indicate Mrs B’s blood tests results on admission to hospital were consistent with underlying liver disease. The results showed elevated liver enzymes (an indication of liver damage), coagulopathy (a condition where the blood’s ability to clot is impaired), macrocytosis (abnormally large red blood cells), thrombocytopaenia (low blood platelet count), hypoalbuminaemia (low levels of albumin, a key protein found in blood plasma) and low urea (a waste product produced in the liver).

37. An initial CT scan performed shortly after admission showed evidence of decompensated liver cirrhosis (an advanced stage of liver disease where the liver can no longer function properly leading to serious complications and a significantly reduced life expectancy). The scan identified peri-oesophageal varices (enlarged veins in the oesophagus found in individuals with serious liver diseases) and ascites (abnormal build-up of fluid in the abdomen).

38. An ultrasound scan on 9 May 2024 confirmed the findings of decompensated liver cirrhosis and showed Mrs B had a shrunken liver with a nodular outline and coarse echotexture (indications of scarring of the liver). Our adviser said the records indicate Mrs B also showed signs of possible hepatic encephalopathy (brain dysfunction caused by liver failure) characterised by her prolonged confusion, and the presence of a liver flap (a flapping tremor of the hands and wrists commonly seen in liver disease and hepatic encephalopathy).

39. The records indicate Mrs B had a Child-Pugh score of class C. The Child-Pugh score is a clinical tool used to assess the severity of chronic liver disease, particularly cirrhosis. It combines five parameters: total bilirubin (a yellow pigment produced by the liver), serum albumin, INR (a measure of blood clotting), ascites, and hepatic encephalopathy. Each parameter is scored from 1 to 3 points, with higher points indicating worse liver function. The total score ranges from 5 to 15, which is then classified into three categories:

• Class A (5–6 points): Well-compensated liver disease • Class B (7–9 points): Significant functional compromise • Class C (10–15 points): Decompensated liver disease

40. The Cirrhosis guidance says a Child-Pugh score of class C represents the most severe stage of liver disease and has a high morbidity and mortality rate. The Cirrhosis guidance says individuals with this degree of liver disease have a low life expectancy with one-year survival rate of 45%.

41. In addition to her advanced liver disease, the records indicate Mrs B’s CT scan also found features suggestive of chronic pancreatitis including pancreatic calcification (calcium deposits in the pancreas). Further investigations identified enzymatic fat necrosis (the destruction of fat tissue caused by the abnormal release of activated pancreatic enzymes) consistent with pancreatic panniculitis (a rare condition characterised by inflammation of the subcutaneous fat tissue and skin caused by underlying pancreatic disorders).

42. The records indicate Mrs B spent a long time in hospital with the above conditions and several individual risk factors which made her more susceptible to infection and/or significant clinical deterioration. Our adviser said the sequence of events during her admission indicate that she was very unwell from the outset with a combination of serious underlying conditions. She contracted an infection and did not recover despite treatment with appropriate antibiotic medication.

43. Our adviser said there is no evidence in the records to indicate that failings identified by the Trust led to Mrs B’s infection of her death. Our adviser said there is no evidence we can point to which would suggest her death would have been prevented had the failings not happened.

44. We carefully considered Ms A’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. As we have set out above, Mrs B had a number of serious underlying health conditions and she became progressively more unwell before developing a serious infection during her admission.

45. We acknowledge the failings identified by the Trust and Ms A’s view that it was because of these failings that her mother developed the infection that led to her death. We found the combination of serious conditions Mrs B had posed a significant risk of infection. These conditions also posed a significant risk to her immediate condition and chances of recovery.

46. We found no evidence which we can point to that would enable us to say she developed an infection due to the failings identified by the Trust, either individually or cumulatively, and not as a result of the severity and combination of her underlying conditions.

1. We have decided to not uphold this complaint. We found no evidence to indicate the failings identified in the Trust’s review of Mrs B’s care lead to her contracting the infection which caused her death.