Decision report 201200160

Summary

Mr C complained about the care and treatment given to his late wife (Mrs C). He said that Mrs C had initially been taken into hospital with a urinary tract infection. The following month, she was transferred to another hospital for rehabilitation and physiotherapy. Later that month she was noted to have red heels, with a blister on one of them. Mrs C was discharged home shortly afterwards and Mr C said that at that time she had pressure sores. Mrs C died some six months later.

Mr C complained that his wife suffered from pressure sores while in the care of the board. He said that she was inadequately nursed and that this contributed to her death. In our investigation we took all the relevant information into account including the board's file of correspondence and Mrs C's clinical notes. We also obtained independent nursing advice about Mrs C's care and treatment.

We upheld all Mr C's complaints. Our investigation found that there was no reason not to discharge Mrs C home with dressings on her feet. However, there was also no evidence to suggest that a wound chart was completed before discharge, which would have assisted community nurses to plan their care for Mrs C. Community nurses were also not told that Mrs C's heels needed dressing and we found that communication between the hospital and the community nurses was poor. Similarly, record-keeping was below a satisfactory standard.

Recommendations

We recommended that the board:

• emphasise to the staff concerned in this case the importance and necessity of keeping properly recorded notes and of using the tools that are available to them to assist in the care and treatment of patients (eg a wound chart);
• apologise to Mr C for their failures in this matter. Also, that the apology makes specific reference to the poor treatment given to Mrs C while she was at home; and
• provide evidence to the Ombudsman about how they assure themselves that the discharge planning standards/policies relating to communication have been addressed