Investigation Report 201103459

  • Report no:
    201103459
  • Date:
    May 2013
  • Body:
    Lothian NHS Board
  • Sector:
    Health

Overview
The complainant (Mr C)'s wife (Mrs C) was admitted to the Western General Hospital (the Hospital). Mrs C is paraplegic and uses a wheelchair. Whilst in the Hospital, she developed pressure ulcers which ultimately required her to go into permanent residence in hospital. Mr C complained about the failure of Lothian NHS Board (the Board) to prevent her pressure ulcers. He also raised concerns about their staff's communication with Mrs C and questioned the appropriateness of the initial decision to discharge her from the Hospital.

Specific complaint and conclusion
The complaint which has been investigated is that care and treatment at the Hospital regarding the pressure ulcers and discharge home, including communication, were unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) provide training to their staff on the proper implementation of their pressure ulcer policies, including the completion of all relevant documentation in the clinical records;
  • (ii) apologise to Mr and Mrs C for the issues highlighted in this report; and
  • (iii) provide this office with evidence of the action taken to implement the action plan with particular reference to ensuring a multi-disciplinary assessment of patients' suitability for discharge.

 

The Board have accepted the recommendations and will act on them accordingly.

Updated: December 11, 2018