Decision Report 201703416

Summary

Miss C complained about the care and treatment provided to her late father (Mr  A) during admissions in Monklands Hospital and Coathill Hospital.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nurse with expertise in pressure ulcer prevention.

Miss C raised concern that Mr A, who had diabetes, was discharged from Monklands Hospital with a large pressure ulcer on his left foot. In response to Miss C's complaint, the board acknowledged that there was little documentation of the care provided for Mr A's feet and they apologised for this. We found no evidence that medical staff reviewed Mr A's feet during this admission and considered that this was unreasonable in the circumstances. We also found a number of failings in the way nursing staff assessed, documented and managed Mr A's feet during the admission. We noted that there was a delay in referral to the podiatry team (the area of medicine which deals with the feet and ankles) and no evidence that Mr A was physically reviewed by podiatry. Finally, we were critical about the lack of information and equipment given to Mr A and his family before discharge and that the board did not ensure that arrangements for ongoing care were in place. We upheld this aspect of Miss C's complaint.

During a subsequent admission in Coathill Hospital, Mr A was found to have fallen. Initially, no injuries were noted by either nursing or medical staff. When Mr A was reviewed by an occupational therapist the day following the fall, pain was noted yet this was not escalated to the medical team. The board apologised to Miss C for this failing. Two days following the fall, nursing staff found Mr A to be in pain and an x-ray was arranged. This identified that Mr A had a broken hip and he received treatment the following day. We found that the initial medical review did not appear to have included an examination to specifically assess if Mr A had suffered any injuries as a result of his fall. We also considered that there was an unreasonable delay in arranging an x-ray and diagnosing Mr A's hip fracture. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings in nursing and medical care, failing to provide sufficient equipment and information prior to discharge, failing to ensure that arrangements for ongoing care were in place and the unreasonable delay in diagnosing Mr A's hip fracture. 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:

• Where a patient has a combination of poor blood supply, diabetes, and wounds on the feet, a medical examination should be carried out prior to discharge.
• All patients with diabetes who have existing foot damage or develop foot damage should be referred to podiatry as soon as the damage is discovered. Patients at risk of developing pressure damage to their feet should be assessed and fitted with protective footwear. Nursing staff should complete a wound assessment chart for every wound a patient has. Patients at risk of developing pressure damage or who have existing pressure damage should have a plan of care in place for interventions at least every two hours. Staff must be able to diagnose and grade pressure damage and accurately report their findings. Where a patient requires specialist assessment by a podiatrist a review should be carried out within a reasonable time.
• Patients and their families/carers should be provided with verbal and written information on pressure ulcer risk, details of a patient's pressure damage and how to manage this whilst preventing further damage, details of follow- up arrangements for wound dressing, a supply of wound dressings and pressure relieving footwear.
• Where a patient has fallen whilst in hospital, a medical examination for injury should be performed promptly.