Decision report 201102885

Summary

Mr A was an elderly man with a history of health problems and restricted mobility. He had been nursed at home for several years.

Mr A was admitted to hospital with confusion, infection and back pain. Nine days after admission, he developed pressure ulcers. Mr A remained in the hospital for around seven weeks until he was transferred to a second hospital, where he remained until his death around three weeks later.

Mr A's son (Mr C) said that his father was at known risk of developing pressure ulcers. He said that the family alerted staff to their concerns about the the need to change Mr A's position. He complained that, despite this, staff at the first hospital unreasonably failed to monitor his father appropriately and change his position frequently enough to prevent pressure ulcers developing.

Mr C also complained that there was an unreasonable delay of nine days in obtaining specialist equipment such as a special mattress. He said that when Mr A was transferred to the second hospital there was a further unreasonable delay of two days in transferring the special mattress between the two hospitals. In addition, Mr C complained that the board's response to the family's complaint about Mr A's care was inadequate.

We upheld Mr C's complaint about the two day delay in the transfer of a special mattress between the hospitals. The board acknowledged there was a delay, and our adviser's view was that such a delay was unacceptable. As a result of this failing, the board introduced a standard operating procedure to avoid future delays. We, therefore, did not find it necessary to make any recommendations about this.

We did not uphold Mr C's other complaints. We understood the family's reasons for concern about Mr A's care and treatment. However, our investigation found that Mr A's pressure areas were monitored and cared for appropriately for the first nine days in hospital. When pressure ulcers developed, they were properly cared for, in line with relevant NHS guidance. From admission to the first hospital, Mr A was on an appropriate mattress based on his pressure ulcer risk assessment score. When the score increased, a special mattress was ordered. This was in line with both the board's guidance and general NHS guidance.

We found that the board's investigation of the family's complaint and their response to it addressed the points made in the family's complaint letter, and was a reasonable reflection of Mr A's condition and the care provided to him.