Decision Report 201402047

Summary

Mr C, who is an independent advocate, complained on behalf of his client (Mrs A) that the board did not take reasonable steps to prevent Mrs A's husband (Mr A) from developing a pressure ulcer (bed sore) during his stay in Inverclyde Royal Hospital. Mr A had terminal cancer and was admitted to hospital for palliative care (care provided solely to prevent or relieve suffering). He was there for ten days, and was then discharged home with no mention of a pressure ulcer. Later on the day of his discharge from hospital, a district nurse examined Mr A and found that he had a pressure ulcer.

We took independent advice from our nursing adviser, who said that the board had not thoroughly assessed Mr A during his admission and so had not recognised his increased risk of developing a pressure ulcer. If this had been done then Mr A's condition would have been more regularly assessed. The adviser was critical that staff relied on the assessments made when he was admitted, and said they had not exercised good clinical judgement. The adviser also said that the record-keeping was poor. In light of these failings, we upheld the complaint. As, however, the board had already taken positive steps to stop this happening again, we made only one recommendation.

Recommendations

We recommended that the board:

• provide Mrs A with information about steps taken to address the shortcomings identified.