Decision Report 201607406

Summary

Miss C complained about the care and treatment provided to her at Victoria Hospital. Miss C complained that when she first presented at the hospital with symptoms relating to an infection in her groin area, she was discharged too early and had to be readmitted later that day. Miss C also complained that the abscess which formed in her groin area was inappropriately drained at her bedside, and that there was a delay in a diagnosis of necrotising fasciitis (a rare infection that destroys the soft tissue of the skin) being made.

We took independent advice from a general surgeon and a consultant physician. We found that Miss C was inappropriately discharged from the hospital on her first admission as she had been newly diagnosed with diabetes and had an ongoing temperature. The advice we received was that it may have been helpful for Miss C to have had input from a diabetologist and earlier surgical management of her skin infection. We also made a recommendation regarding the documentation of timings in medical records as we found this to be poor.

We further found that the drainage procedure carried out at Miss C's bedside was not reasonable as pain relief was not documented, and the signs that were present at this point, namely skin blistering and fluid filled tissues, were not reasonably acted upon.

Finally, we found that there was an unreasonable delay in the diagnosis of necrotising fasciitis as, when there were clear features of this occurring, the appropriate action was not taken in a timely manner. Additionally, the advice we received noted that there was clear indication for surgical incision and drainage at a far earlier point than was carried out and that, had surgical treatment been carried out at an earlier point, necrotising fasciitis may not have occurred. We upheld all of Miss C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for inappropriately discharging her from hospital, inappropriately carrying out a clinical procedure at her bedside and unreasonably delaying in reaching a diagnosis of necrotising fasciitis. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• All entries in clinical records should be correctly dated and timed.
• The board should ensure it has clear guidelines that comply with recognised standards for how to manage skin and soft tissue infections, which include when surgical treatment should be commenced. Staff should be competent to apply them to an acceptable standard.
• In otherwise unwell patients with newly diagnosed diabetes, consideration should be given to seeking input from a diabetologist.
• Surgical staff should be familiar with signs of necrotising skin and soft tissue infections.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.