Decision Report 201703557

Summary

Mr C complained about the standard of pressure area care which his mother (Mrs A) received while she was a patient in Woodend Hospital. Mrs A was in hospital for a number of months and, due to her reduced mobility, developed a grade two pressure ulcer which progressed to a grade four pressure ulcer. A grade four pressure ulcer is the most severe kind, and people with grade four pressure ulcers have a high risk of developing life-threatening infections.

We took independent advice from a nursing adviser who noted that appropriate risk assessments were not carried out and incorrect equipment had been used in an effort to prevent the development of and healing of pressure ulcers. While the staff had taken action to change Mrs A's position in bed and when she was sitting in a chair, these were not changed frequently enough. There was also a delay by the staff in referring Mrs A for an assessment by the tissue viability service. We upheld the complaint.

However, we did note that the board have since carried out an investigation and audit which identified learning opportunities for staff in regards to knowledge and awareness of pressure area care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the failings in pressure area care. The apology should meet the standards set out in the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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.