Trust refused to readmit older woman with gangrene

What happened

The ulcer worsened over a period of four months and caused Mrs Y intense pain. Her GP suspected peripheral vascular disease (a build–up of fatty deposits in the arteries that restricts the blood supply to leg muscles). He arranged tests.

On the second of two home visits, another GP diagnosed gangrene and Mrs Y was admitted to hospital. Investigations revealed that a large artery in her thigh was blocked. Staff considered different options, including an operation to try to restore blood flow to Mrs Y's leg, an amputation or allowing the condition to stabilise while managing the pain.

In discussion with doctors, Mrs Y's family chose the latter and she was discharged to a nursing home after three and a half weeks in hospital.

Mrs Y's gangrene then worsened and spread to her ankle. Two weeks after her discharge, a GP called the hospital to make an urgent referral and to arrange for her to be readmitted. The hospital told the GP that Mrs Y was not fit for surgery and the hospital could not do anything for her. A hospice nurse was assigned to arrange an end–of–life care plan.

Mrs Y's condition continued to decline rapidly and her family were told that she would die.

After a further two weeks, at the prompting of nursing home staff, a GP arranged for her to be taken by ambulance to the Trust. She was admitted through the emergency department and her leg was later amputated. The hospital discharged her to the nursing home.

What we found

We investigated complaints about the GP Practice and the hospital Trust. The care provided by the Practice had been reasonable, although its record keeping and complaint handling needed improvement.

Mrs Y's care at the Trust was reasonable during her first admission. However, she was wrongly refused readmission by a junior doctor, who made an error of clinical judgment. As a result, her condition deteriorated very significantly and she was placed at high risk of death.

Putting it right

The Trust reviewed our recommendations and provided a formal response, including an apology and actions to avoid similar problems in future, and the Practice apologised and reviewed its record keeping to make sure that it complies with General Medical Council guidance. The Trust also paid Mrs Y £2,000 in recognition of the distress, pain and unnecessary risk caused.