Overview
The complainants (Mr and Mrs C) raised a number of concerns that their relative, Mrs A (Mrs C's sister, Mr C's sister-in-law), had suffered as a result of a break in the skin of her left heel not being adequately monitored and treated. They also raised concerns regarding a potential communication breakdown between two hospitals when Mrs A was transferred from one hospital to the other.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) staff failed to inform Mrs A that she was suffering from a potential pressure sore on her left heel (upheld);
- (b) staff at Western Infirmary, Glasgow (Hospital 1) failed to treat the potential pressure sore (no finding);
- (c) Hospital 1 failed to advise Drumchapel Hospital (Hospital 2) about the potential pressure sore at the time of transfer (not upheld); and
- (d) Hospital 2 failed to diagnose and treat the sore for approximately ten days after Mrs A's admission (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board reiterate to the staff involved the importance of making clear notes after assessments.
The Board have accepted the recommendation and will act on it accordingly.