Decision Report 201907743

Summary

C complained about the treatment provided to their spouse (A) by the board. A underwent knee replacement surgery. After the surgery, A's health declined and A died approximately five months later. C raised a number of issues relating to the surgery itself as well as the care and treatment provided afterward.

We took independent advice about this complaint.

We considered C's complaint on how the board failed to carry out the surgery in a reasonable manner. We found the board carried out the surgery in a reasonable manner, based on the experience of the surgeon, operation note and postoperative x-rays. As such, we did not uphold the complaint.

We considered C's complaint that the board failed to provide reasonable nursing care after A's surgery. We found that while some elements of nursing care were reasonable, the main type of care provided by the board; wound care, was unreasonable. We found four key points which were unreasonable and that these could have been addressed if a referral had been made to the tissue viability service once it was clear that the wound was deteriorating. This referral was not made. Therefore, we upheld this complaint.

C also complained that the board failed to provide reasonable treatment to A after the surgery. We found that there was a delay in the provision of A receiving antibiotics and, while this was not best practice, it was not unreasonable. We found that the actions in response to A's deterioration, including transfusions, surgery and medication, were reasonable and A's condition was reasonably monitored. Therefore, we did not uphold the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable wound care. 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:

• Allergies should be consistently recorded in patient's medical records.
• Appropriate wound assessments should be carried out for patients.
• Dressings should be removed immediately if it is known the patient is allergic to them.
• Where appropriate, referrals should be made to a tissue viability nurse specialist.
• Wounds should be treated with appropriate wound care products based on the wound assessment.

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.