Decision report 201103826

Summary

Mrs C complained about the treatment that her late husband (Mr C) received after he was admitted to hospital with an infected ulcer on his toe. Mrs C also complained that staff did not adequately monitor how much pain her husband was experiencing and did not make adequate arrangements when he was discharged from hospital on three separate occasions, including arranging transport home.

Mr C developed ulcers and ischemia (insufficient blood flow) to his foot and underwent surgery to improve the blood flow through the artery below his knee. He was discharged shortly afterwards but a few weeks later his toe became necrotic (the tissue in the toe died because of a lack of blood and oxygen). Mr C was admitted to hospital again and the decision was taken to observe and wait for auto amputation (for the toe to fall off spontaneously). When the condition of his toe worsened, Mr C had emergency surgery, resulting in some toes being amputated. However, he died a few weeks later. Mrs C said there was an unreasonable delay in fully investigating and treating her husband's toe, which meant he had to have more radical surgery. Mrs C believed that her husband would still be alive if an operation been carried out sooner and had he not been discharged several times.

After taking independent advice from one of our medical advisers, we did not uphold Mrs C's complaints. We found that Mr C received appropriate treatment from a podiatrist (a clinician who diagnoses and treats abnormalities of the lower limb) and that there was no undue delay in referring him to a vascular specialist (a clinician who treats disorders of the circulatory system). The treatment provided by vascular surgeons was also timely and appropriate.

Whilst we identified that on one occasion there was an error with Mr C's pain relief medication, our adviser said that overall his pain was monitored adequately and appropriate pain relief prescribed. Finally, we found that the hospital acted reasonably in not providing Mr C with transport home after he was discharged, as he did not meet the relevant criteria.