Sepsis caused by an untreated pressure sore
The complaint
Miss O complained about the care that Tameside and Glossop Integrated Care NHS Foundation Trust gave her father, Mr O, between November 2017 and January 2018.
Mr O had multiple health conditions, including dementia, and his family supported his daily living. On 16 November 2017, he collapsed and went to A&E in an ambulance. He went home a few days later.
He went to A&E again on 25 November with a temperature and sleepiness. The Trust suggested that he had a urinary tract infection and treated him for possible sepsis. He was moved to the medical assessment unit and then to a ward.
On 27 December, the Trust noted a moisture lesion (sore skin, which sometimes blisters, caused by exposure to wetness over a long period of time) to Mr O’s sacrum (bone at the base of the spine). A few days later his condition got worse again. The Trust treated him for possible hospital-acquired pneumonia and his condition improved.
On 4 January, the Trust noted a grade 2 pressure ulcer (damage to the skin caused by pressure) and moisture lesion to Mr O’s sacrum. Four days later, they applied barrier cream.
The Trust took blood cultures on 15 January, which grew a type of bacteria. The Trust gave Mr O antibiotics and fluids. The Trust noted the likely cause was the pressure ulcer.
Mr O’s condition got worse on 21 January. The Trust decided to stop active treatment and told his family there was nothing more it could do.
Mr O moved to a hospice the next day, where staff documented a grade 4 lesion to his sacrum, with moisture damage. Mr O sadly died a few days later. The cause of death was sepsis caused by the sacral pressure sore that had remained untreated.
What we found
We found that the Trust did not assess Mr O’s risk of developing a pressure ulcer and did not put in place an individualised care plan. This meant the Trust did not consistently assess Mr O’s skin, provide pressure relief or reposition Mr O. The documentation of the care it provided was poor. The Trust did not refer Mr O to the tissue viability nurses at the right time.
These failings led to Mr O’s skin integrity deteriorating, developing sepsis, and then sadly to his death. This would have been avoided if the failings had not happened.
We found failings in the Trust’s record-keeping, particularly relating to care plans and fluid balance. This cast doubt on the care provided and made it harder for us and the Trust to be able to address Miss O’s concerns.
Mr O got the pressure sore while in hospital. This was a patient safety incident, which should have been discussed with Mr O’s daughters who were his main carers. The Trust should have communicated with the family earlier about the damage to Mr O’s skin.
We found that Mr O’s death was avoidable and happened because of the Trust’s actions.
Putting things right
We said the Trust should write to Miss O to accept responsibility for the failings and apologise for the effect they had. We said it should produce an action plan explaining how it will stop the failings from happening again, and send a copy to Miss O, us, the Care Quality Commission and NHS Improvement.