Decision Report 202202672

Summary

C complained on behalf of their spouse (A) about the care provided by the practice. A developed a wound in their left leg and received several courses of antibiotics and wound treatment but the wound deteriorated. A was referred to a vascular specialist several weeks after they first attended the practice. A was later admitted to hospital and died.

We took independent advice from a practice nurse adviser. We found that there were particular concerns about the lack of robust record keeping. The required wound assessment was not carried out or repeated at least every seven days as required. There was no record of the rationale behind the dressings used. There was no record of leg ulcer assessment being carried out and no documentation to support why this was the case until the referral. We found that the use of inadine (a type of surgical dressing) was inappropriate and that the choices for other wound dressings chosen were not detailed. We also found that the ongoing referral was not made in a timely manner.

Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. 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:

• Patients requiring wound care should be managed in accordance with relevant guidance and timely referrals made. In particular, the wound should be appropriately assessed, documented and reviewed, appropriate wound swabs taken and appropriate dressings applied and checked.

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.