Overview
The complainant, Mr C , was concerned that his late father (Mr A) had suffered serious pressure sores while in the Southern General Hospital (Hospital 1) following an operation on both his knees. Mr C felt that the decision to operate had not been taken appropriately and that the care provided while Mr A was in Hospital 1 was inadequate. Mr C was also unhappy about the way the Board had responded to concerns raised by him and his family.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the decision to operate was not appropriate, in that further tests should have been taken prior to the operation (upheld);
- (b) the post-operative care provided to Mr A was inadequate (upheld);
- (c) communication with Mr A and his family, concerning Mr A's care and treatment, was not adequate (upheld); and
- (d) the Board did not respond appropriately to the complaint raised by Mr C (partially upheld, to the extent that there was a delay in responding with no reasonable explanation given for this).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) undertake a root cause analysis or similar tool to examine the reason why the pressure ulcers developed and why there was no proactive treatment once this occurred;
- (ii) provide the policy/guidance for the assessment and treatment of pressure ulcers, with particular reference to the referral to the specialist teams in tissue viability, pain and nutrition; undertake an audit to review the processes; and provide an action plan to address any shortcomings;
- (iii) undertake an audit of documentation to include nursing assessment, pain assessment and nursing care of Wards A and B;
- (iv) provide evidence of the education and training programme provided to nursing staff in relation to the assessment and care of pressure ulcers;
- (v) undertake an external peer review of the nursing care in Ward A, to include an examination of the clinical leadership and management, patient experience and quality of care. In undertaking the review, consideration should be given to Improvement Methodology and the Scottish Government initiatives outlined in Leading Better Care;
- (vi) provide details of the action plan created as a result of the above recommendations and provide updates where relevant. Action plans should be specific, measurable, achievable, realistic and timely (SMART) and include robust quality indicators such as the Clinical Quality Indicator for Pressure Ulcer Prevention;
- (vii) as a priority, review the documentation provided to patients and provide the Ombudsman with the results of this;
- (viii) provide details of the audit made in response to report 200600345 and any action taken as a result;
- (ix) if not covered by that audit, undertake a specific audit of communication within Hospital 1, to include communication with families, and between staff;
- (x) reinforce to clinical staff the importance of responding to requests from complaint handling staff timeously; and
- (xi) make a full apology to Mr C and his family for the failings identified in this report.
The Board have accepted the recommendations and will act on them accordingly.