Decision Report 202005027

Summary

C complained about the community nursing care their parent (A) received for leg ulcers which had become infected. We took independent nursing advice, which highlighted that inappropriate dressings were applied to A's wound for a period, and also appropriate supplies of dressings were not obtained in a timely manner. When the wound did not improve, there was initially a failure to escalate the matter. We noted that there was appropriate escalation later and the wound management was reasonable from this point. On balance, we upheld this complaint.

C also complained that A was discharged from University Hospital Hairmyres (UHH) with an infection still present. We noted that A was receiving antibiotics and a follow-up plan was in place, and that the discharge was reasonable even in the presence of infection. We did not uphold this complaint. C also complained that A was not reasonably assessed when they attended UHH emergency department. C was unhappy that A was assessed without removal of their bandage, and that no swabs were taken. We took independent advice from a consultant in emergency medicine. We noted that there was a reasonable focus on A's knee pain/swelling and no unreasonable omission in terms of examining the leg wound. We did not uphold this complaint.

Finally, C complained that the board's response to their complaint failed to refer to A's fall in hospital. In responding to our enquiries, the board offered assurances that A had not fallen, but rather experienced a feinting episode due to low blood pressure. We confirmed that this was supported by the medical notes. We considered the board to have reasonably explained why this was not referred to in their complaint response, and we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to appropriately manage A's leg ulcers for a period. 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:

• Appropriate dressing products are used for leg ulcer management with wound dressings being available at the time of dressing changes.
• Nursing staff make timely referrals to the Leg Ulcer Service if a wound is not progressing.

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.