Decision report 201103179

Summary

After Mrs A had a knee replacement operation she was discharged home into the care of the district nursing service (district nurses visit and treat patients at home). Her daughter (Mrs C) complained about the care Mrs A then received - in particular, that two clips were not removed. Mrs C said that this caused her mother to suffer an infection, and that this was not properly treated in that on one occasion, dressings were not available. She also said that Mrs A was not provided with antibiotics quickly enough. Mrs C considered that her mother suffered unnecessarily because of this, and lost mobility and independence.

We investigated the complaint and took advice from our nursing adviser. We found that, contrary to what Mrs C thought, wound clips are not normally counted as they are put in and taken out, and are generally obvious. Although two clips were left in Mrs A's knee for a short time, the adviser could not conclude that this led to the infection. However, the adviser also said that the notes taken at visits were not of good quality and that not all actions taken were noted. Nevertheless, the records suggested that there was no delay in giving Mrs A appropriate antibiotics. Although it was regrettable that Mrs A contacted an infection, we could not determine with certainty that this was as a result of a lack of care. We did, however, uphold Mrs C's complaint that on one occasion the wound was not dressed.

Recommendations

We recommended that the board:

• emphasise to all district nursing staff the importance of adhering to the Nursing and Midwifery Council 2009 Guidelines 'Record keeping