Earlier diagnosis and treatment could have decreased patient's chances of developing painful ulcers

What happened

Mrs K was in her nineties and suffered with osteoarthritis (a condition that affects the joints) but she was well and had a good quality of life. To help with her mobility, Mrs K had injections in her knee every six months.

Mrs K went to A&E with pain in her knee. However, after an examination, she was discharged and told to come back if the pain got worse. She did go back the next day and investigations found that she had an infection and she was admitted to hospital.

The infection was treated but Mrs K did not respond to the antibiotics. The Trust discovered that she had developed gastric ulcers. She was treated for these and was placed on the Liverpool Care Pathway (a way of caring for patients who are in the final days or hours of life) the day before her death. However, not all of the medication suggested by the palliative care team was started before she died.

Mrs T believed that her mother died in agonising pain as a result of the care she received from the Trust. She said her mother died two weeks after getting a routine injection in her knee.

What we found

The examination performed in A&E when Mrs K first went there was not thorough enough as there were signs of infection. Mrs K should have been admitted to hospital then for treatment. However, when she was admitted the next day, the treatment she had was appropriate.

We also found that the Trust should have given Mrs K another medication alongside the non-steroidal anti-inflammatory drugs, to decrease her chances of developing the painful ulcers.

We found that her pain relief was appropriately monitored and she was given appropriate amounts of pain relief. We did not find a delay in placing Mrs K on the Liverpool Care Pathway.

We found that the Trust should have undertaken a serious untoward incident investigation into the fact that an infection was contracted following a routine injection. This should have looked into the aseptic procedures used, to see whether the Trust was at fault. This was not done and that was a significant failing.

We could not conclude that Mrs K's death could have been avoided, but the infection could have been diagnosed and treated earlier and her chances of developing painful ulcers could have been decreased. As a result her family will never know whether earlier diagnosis would have saved Mrs K, which was a significant failing.

Putting it right

The Trust apologised to Mrs T and paid her £1,000 in recognition of the impact of the failings on her. It also reviewed its serious untoward incident investigations policy and identified lessons learned from our investigation.