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Mrs B complained about the care and treatment given to her son
(“Mr C”), by the Podiatry Service and during two hospital admissions,
when he suffered foot problems associated with diabetes. Mrs B said
the Podiatry Service was inadequate, Mr C was discharged from his first
admission too soon and the Health Board failed to provide adequate
protection for Mr C against Deep Vein Thrombosis (DVT)1 or
Pulmonary Embolism (PE)2 following an operation to amputate an
infected toe during his second admission to hospital, and that this
resulted in Mr C suffering a PE 12 days later, from which he sadly died.

The investigation found that earlier referral, by the Podiatry Service, to a
specialist team might have resulted in earlier treatment of his condition
and might have prevented the need to amputate Mr C’s toe. The
investigation found that further steps should have been taken before
Mr C was discharged, following his first hospital admission, and had
these steps been taken Mr C’s care might have been managed

The investigation also found that Mr C was at increased risk of DVT/PE
and that protection against DVT/PE should have continued after he was
discharged from his second hospital admission. Had Mr C received
medication to reduce the risk of DVT/PE it might have prevented Mr C
from developing the PE which caused his death. It follows that Mr C’s
death might have been avoided.

The Health Board agreed to implement the following recommendations:

(a) Apologise, in writing, to Mrs B for the failings identified in this report.

(b) Make a payment of £4000 in recognition of the failings identified in
the report.

(c) Arrange for the clinicians involved in Mr C’s first discharge from
hospital to review this case with their supervisors and examine what
lessons can be learned from the failures identified in the report.

(d) Undertake a root cause analysis investigation of this case to establish why no assessment was undertaken of Mr C’s risk of developing DVT/PE once he had been discharged. An action plan should be created to prevent this situation arising again. The findings and action plan should be shared with the Ombudsman.

(e) Arrange for the staff involved in Mr C’s care during and following the
amputation of his toe to review the case and the results of the root
cause analysis investigation with their supervisors.

(f) Ensure that the Podiatrist involved in Mr C’s care reviews the case
with their supervisor and receives further training on the use of the
referral pathway.

(g) Remind complaints team staff of the importance of providing timely
and regular updates to complainants.