Decision Report 201909979

Summary

C complained about the nursing care and treatment they received during their admission to Ninewells Hospital. This related to the treatment of a pressure ulcer which C complained was left to deteriorate to the extent that on discharge it was worse than on admission. They said that as a consequence, their treatment had to be continued intensively at home.

The board apologised that C's wound had been worse on discharge and accepted that the simple dressings used by nursing staff would not have encouraged wound healing. They also accepted that there was a requirement to support all staff members to attend an update training session on wound care and that encouragement needed to be given to all team members to have the confidence to ask their peers or others working within the multidisciplinary team for advice and assistance.

We took independent advice from a nursing adviser. We found that there had been a failure to assess, measure and treat C's wound in accordance with the Scottish adapted pressure ulcer grading tool and Healthcare Improvement Scotland (HIS) Pressure Ulcer Standards (2018). We also found that the review carried out by the board had not been thorough enough, a number of failings had not been identified and that the action already taken by the board was not enough to demonstrate that there had been improvement with regard to pressure ulcer assessment and grading. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to assess, measure and treat their pressure ulcer in accordance with the Scottish adapted pressure ulcer grading tool and HIS Pressure Ulcer Standards (2018). The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• All pressure ulcers should be assessed, measured and treated in accordance with the Scottish adapted pressure ulcer grading tool and HIS Pressure Ulcer Standards (2018).

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.