Decision Report 202202485

Summary

C complained about the care and treatment provided to their spouse (A). A stayed in critical care wards after surgery and acquired wounds to their back and shoulders. C complained that A’s wounds were not appropriately documented or treated.

In response to C’s complaint, the board acknowledged that documentation of A’s wounds was not started in critical care wards, and A’s wounds were not initially logged on the board’s system for reporting adverse events. The board told us that after C’s complaint, the tissue viability service developed online learning for staff, and developed and promoted a wound management policy. The board apologised that A sustained wounds after surgery.

We took independent advice from a nurse with a specialism in wound care. We agreed that the board did not reasonably document C’s wounds; however, we also found that they did not follow their guidelines in treating A’s wounds. We found that there was a delay in referral to a tissue viability specialist; a lack of skin inspection; inadequate repositioning to prevent pressure damage occurring or deteriorating; and inappropriate wound management. We also found that the board did not provide C with a full and informed complaint response. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A 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 should be regularly assessed for tissue damage in line with board procedures. Where tissue damage is found, appropriate treatment including timely escalation to a tissue viability specialist as required should be provided.

In relation to complaints handling, we recommended:

• The board’s complaint handling monitoring and governance system should ensure that complaints are properly investigated and responded to; are accurate; and that failings and good practice are identified.

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.