Decision Report 201703784

Summary

Mrs C complained about the care and treatment that her mother (Mrs A) received at Dumfries and Galloway Royal Infirmary. She was admitted to hospital with a large haematoma (a localised collection of blood outside the blood vessels) on her right leg. Mrs A received treatment and was later discharged. After a visit from the district nurse, Mrs A was readmitted to hospital and her leg was operated on the following day. Mrs A was eventually discharged to a hospital outwith the board. Mrs C complained that the board failed to provide appropriate treatment for Mrs A's haematoma following her admission to hospital. She also complained that the board unreasonably discharged Mrs A from hospital.

We took independent advice from a registered general nurse and a consultant in general medicine. We found that there was a lack of wound assessment, inappropriate wound assessment and a failure to debride the wound (to remove the damaged tissue from the wound) before discharge. We were also concerned about the use of dressings which stuck to Mrs A's leg and considered Mrs A should have been referred to a wound care specialist. We considered that these failings would have contributed to the time taken for Mrs A's wound to heal and her pain during that period. Initially Mrs A received appropriate medical care, with appropriate investigations carried out on admission and clear attention to detail. However, we found that Mrs A should have received a greater level of medical review prior to discharge, and her care therefore fell below a reasonable standard. We upheld this part of Mrs C's complaint.

In relation to Mrs A's discharge, we found that Mrs A should have received a debridement before discharge. We were also concerned about the level of medical review Mrs A received in the days before her discharge. Given the severity of Mrs A's wound a few days later, and the lack of detail in the records at the time of discharge, we were not confident that Mrs A's wound had improved significantly and enough for Mrs A to return home safely. Therefore, we considered Mrs A's discharge to be unreasonable and upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failing to appropriately assess and document the wound on admission, correctly assess the wound, apply appropriate dressings, debride the wound and, refer Mrs A to a wound care specialist. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Patients in a similar situation should have a wound chart completed on admission and updated at every dressing change.
• From admission, a wound should be measured using a measuring scale to ensure accuracy of size. Staff should be knowledgeable on the type of tissue that is present on the wound bed and be competent in this prior to completing a wound assessment chart.
• A non-adherent contact layer or non-adherent dressing should be applied to the wound bed. Gauze swabs should not be used as a wound dressing.
• Where appropriate, a wound bed should be debrided without surgical intervention prior to the patient being discharged home.
• Patients should typically be seen by a doctor at least once a week.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.