Overview
The complainant (Mr C) raised concerns about the care and treatment of his late mother (Mrs A) during a 12 week stay in three of Lothian NHS Board (the Board)’s hospitals. During this period, Mrs A developed pressure ulcers on the heels of both her feet and at the base of her spine. One of these pressure ulcers became very severe, and eventually became infected. This infection spread to Mrs A's bone, and ultimately led to her death, six weeks after discharge. Mr C has complained that, had she not developed pressure ulcers, she would have lived longer.
Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to take reasonable steps to prevent Mrs A developing pressure ulcers and they failed to adequately manage these (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- provide an update on the action that has been taken to implement recent recommendations from Health Improvement Scotland and my office on the care and treatment of patients in relation to the risk and treatment of pressure ulcers;
- conduct a peer review of the prevention, care and management of pressure ulcers in the ward in Hospital 2 where Mrs A stayed;
- develop an action plan for improvements identified through the peer review, including education and training, and share this with my office; and
- apologise to Mr C for the failures identified in this report in relation to Mrs A's care and treatment, for the pain and suffering experienced by Mrs A and for the inaccurate information provided to Mr C in the Board's initial response to his complaint.
The Board have accepted the recommendations and will act on them accordingly.