Decision Report 201910693

Summary

C complained about the treatment their spouse (A) received for their pressure sores from district nurses. When A died, one of the main causes of death was noted to be multiple pressure sores. C said that there was no examination by a GP at any point. They believed the pressure sores had become infected, causing sepsis and leading to A’s death.

The board outlined the steps district nurses had taken when they identified that A’s sacral and heel pressure areas were starting to break down. They told us that over a four-month period, district nursing staff carried out more than 80 visits as well as providing support over the phone. They said the district nursing team involved A’s GP and the tissue viability service, who agreed with the care and advice that was being provided.

We took independent advice from a nursing adviser. We found that A’s clinical records showed risk factors which increased their risk of developing skin damage: weight loss, poor mobility and double incontinence. We noted that the advice to patients with pressure sores is to move and regularly change position and to use a pressure relieving mattress, cushions and boots. District nurses ordered appropriate equipment for A and monitored A’s pressure areas closely. We found that there was evidence in the notes of appropriate advice being given to A and C regarding sitting in a chair for a long period of time and the detrimental effect this could have on the skin, especially the heels and sacrum. The boots provided to A were returned to the equipment store despite documented advice that these should be worn.

We considered that there was clear evidence of partnership working between the carers, district nurses, and the wider multi-disciplinary team. Noting the complications associated with A’s incontinence, we found that the documented evidence demonstrated the appropriate treatment being delivered.

Therefore, we did not uphold this complaint.