Summary
Mrs C was admitted to Glasgow Royal Infirmary in January 2013 to get treatment for a skin infection in her left leg. Mrs C has spina bifida (a condition where the spine does not develop properly, leaving a gap in the spine) and lymphoedema (a build-up of fluid which causes swelling in an area of the body) which means that she has problems moving around. She developed pressure ulcers on her left heel and calf, which were still there when she was discharged. When she got home, Mrs C also found that a pressure ulcer had developed on her buttock. She was readmitted to the hospital in February 2013 as one of the pressure ulcers was infected, and discharged a few weeks later. She was again admitted in December 2013.
Mrs C felt that, each time she was admitted to the hospital, her risk of pressure ulcers was not properly assessed and that, due to her existing medical conditions, she should have been placed in the 'very high risk' category. She said that the pressure ulcers developed because of the incorrect assessment and due to a lack of appropriate care. She said that she had suffered a great deal of pain and discomfort, as well as scarring, which continued to cause her distress. With the help of an advice worker, Mrs C complained to the board.
The board apologised that Mrs C felt that her pre-existing medical conditions were not taken into account. They set out the timeline of events across her three admissions to hospital, stating that she had been assessed as requiring a low level of support. When she had needed a pressure-relieving mattress when she left hospital on the second occasion, they said that this had been provided.
They said that she was assessed by a district nurse at home and continued to receive treatment for a pressure ulcer at the base of her spine until the end of July 2013. The board said that the readmission notes for Mrs C's third admission to hospital state that her skin was healthy and, although she had previously developed pressure ulcers when she was unwell, she did not require pressure-relieving equipment because she was assessed as being able to adjust her own weight whilst in bed. The board said it was documented that Mrs C's husband (Mr C) had insisted that a pressure-relieving mattress was ordered for Mrs C, and he had been extremely unhappy that one had not been provided. Finally, they said that staff had carefully considered Mrs C's condition and treatment, and they were sorry that she had been dissatisfied with her care in the hospital.
Mrs C was dissatisfied with the board's response to her complaint and contacted my office, with the help of an advice worker. I took independent advice from a nursing adviser who considered that, as Mrs C has spina bifida, she was at very high risk of developing pressure ulcers during her admissions to hospital. The adviser found no evidence that the nursing staff took Mrs C's pre-existing conditions into account or put steps in place to prevent pressure ulcers occurring. In particular, the Waterlow risk assessment charts (a pressure ulcer risk assessment tool) completed for each hospital admission were not marked properly. The adviser said that, as Mrs C has reduced sensation below the waist (because of spina bifida), she should have had five extra points added to her Waterlow score. This would have put her into the 'high risk' category. During the second hospital admission, the adviser considered that the delay of several days for a tissue viability nurse to provide advice on Mrs C's care, and for a pressure-relieving mattress to be arranged, was unacceptable. The adviser also noted that the nursing staff involved in an incident when Mr C was very angry about Mrs C's treatment and the delays experienced may benefit from education and training in front-line resolution. The adviser also found it 'shocking' that the board had not determined and admitted their failings in Mrs C's care and treatment when they investigated her complaint.
The advice I have received is that nursing staff failed to take into account Mrs C's specific needs due to her spina bifida and, as a result, failed to appropriately assess and manage her pressure areas on each of her admissions to the hospital. There was also a failure by the board to acknowledge these failings while carrying out their investigation of Mrs C's complaint. I am critical of these failings and uphold the complaint.
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) review the training for nursing staff on the assessment, prevention and care of pressure ulcers, particularly where a patient has reduced sensation to the limbs;
- (ii) ensure the tissue viability team review the mechanism for recording patients who are 'special risk', particularly patients with reduced sensation such as spina bifida;
- (iii) carry out a review of the reasons why there was a delay in the involvement of the tissue viability team in Mrs C's care; and advise this office of the action taken to ensure that lessons are learned from this complaint;
- (iv) review the education and training in early resolution skills for the nursing staff involved when dealing with patients and their families who have raised concerns about their care and treatment; and
- (v) apologise to Mrs C for the failings identified in her care and treatment.