Decision report 201103214

Summary
Mrs C had surgery in hospital to remove a soft tissue lump from her right thigh. She said that a few days later the wound had become red and infected. She contacted NHS 24 who referred her to an out-of-hours (OOH) GP service where a nurse prescribed antibiotics. Mrs C returned home, but her condition worsened and later that day NHS 24 arranged for an ambulance to transfer her to hospital where she was diagnosed with a skin infection and an infection of the thigh wound. Mrs C had a further surgical excision and drainage, and the wound was left open to heal from the inside. She received antibiotics intravenously (directly into a vein) and was discharged on oral antibiotics.

Mrs C complained that the hospital failed to prescribe her with antibiotics after the initial surgery, which she believed might have prevented the infection she later contracted. She also said that the OOH service failed to take her seriously and recognise the seriousness of her condition. Mrs C said that as a result of the failure to provide antibiotics and the failures in the care and treatment she received from the OOH service, she has struggled to recover from her operation and continues to have difficulty in walking.

After taking advice from our medical adviser, we found that the hospital's decision not to prescribe Mrs C antibiotics after her initial surgery was reasonable. However, we also found that the OOH nurse failed to recognise the significance of Mrs C's symptoms and admit her to hospital, although our medical adviser said that this would not have affected the outcome.

Recommendations
We recommended that the board:

• have the relevant staff review the management of this case in light of the findings; and
• apologise to Mrs C.