Decision report 201103411

Summary

Mrs C complained that the health board unreasonably failed to provide a home podiatry visit for her elderly father (Mr A). Podiatry is the branch of medicine related to disorders of the foot, ankle and lower extremity.

Mrs C also complained that there was unreasonable failure to maintain Mr A's feet to an acceptable standard and to make a referral to a specialist team when required. Mrs C had concerns about the method of making home visits, about comments in some of the notes, and said there were unreasonable delays and a failure to answer her questions during the complaints process.

Mr A had a significant history of multiple illnesses, including insulin dependent diabetes and mobility problems. These were made worse in cold weather. As is standard for diabetics within the NHS, Mr A had had a podiatry assessment and was receiving regular podiatry treatment - usually attending his local clinic. However, in early December 2010 there had been heavy snowfalls and he was unable to attend a scheduled appointment. Mrs C telephoned the clinic to ask for a home visit. She said she found the attitude of the staff members she spoke to unacceptable, and that she was told that a visit would not be arranged or at least not for some weeks.

Mrs C was concerned about this arrangement as her father had had previous problems with diabetic ulcers on his feet and was complaining of a sore right foot. She spoke with the service director, and a home visit was arranged for the next day. Mr A received several treatments at home during December 2010. He was referred to the specialist team at the end of December and seen the next day. He was immediately admitted to hospital for treatment of an infected diabetic ulcer on his toe. Mr A was discharged in mid January 2011. He was readmitted five days later and died in hospital in February 2011. The primary cause of death was sepsis (infection).

Our investigation included taking independent advice from a podiatrist and a physician, and we upheld all Mrs C's complaints. The podiatrist said that although in general Mr A's feet had been maintained to a reasonable standard, by early December 2010 it should have been clear to the podiatrists that the ulcer was not healing and Mr A should have been referred to the specialist team at that stage. The podiatry adviser also found fault with the general lack of detail in the notes and said that there were some subjective rather than objective comments.

Having seen Mr A's medical records, the physician adviser said that although sepsis was the primary cause of Mr A's death it was not directly caused by the infected toe. However, Mr A had been treated for some time with antibiotics to try to address the infection in his toe. Although this was appropriate treatment, use of antibiotics in this way can kill off the natural pathogens (bacteria) within the digestive system. This can pre-dispose a patient to contracting Clostridium Difficile infection, which is what happened to Mr A. Such infection can produce a range of symptoms from diarrhoea to severe and overwhelming infection, particularly in a patient such as Mr A, with other significant medical problems. Therefore, although the infected toe did not directly lead to Mr A's death, it was a factor in it.

Recommendations

We recommended that the board:

• apologise for the deficiencies identified in our investigation;
• report on their review of the process for home visits;
• review the standard of podiatry notes; and
• provide awareness training on SIGN 116 (guidelines on the management of diabetes).