Summary
Mr C complained to the Ombudsman about the care and treatment he received during a three-week admission to Wishaw General Hospital, when he developed a pressure ulcer which required district nursing care for five months after his discharge. Mr C said that nursing staff did not take sufficient action to monitor his risk of developing a pressure ulcer.
My complaints reviewer took independent medical advice on Mr C's case from a nurse. The adviser said that the nursing staff unreasonably failed to recognise that Mr C was at high risk of developing a pressure ulcer and, therefore, failed to provide care/assess Mr C using the SSKIN care bundle (a five-step care plan for pressure ulcer prevention). The adviser said the Malnutrition Universal Screening Tool or MUST (a way to screen patients to identify and treat adults at risk of malnutrition) was completed inaccurately on all three occasions it was completed. Had concern about Mr C's weight loss been noted in the MUST and the correct score applied, this would have resulted in Mr C being deemed at high risk of developing a pressure ulcer and a high risk care plan being used. If the nursing staff had assessed Mr C correctly and used the SSKIN care bundle, it is likely that he would not have developed a pressure ulcer. The board have acknowledged that they did not carry out visual inspections of Mr C's pressure areas and I am critical of them in this regard.
The adviser said that the fact that Mr C developed a pressure ulcer in the hospital which appeared to require district nursing care for five months after Mr C's discharge, suggested that the nursing staff failed to provide Mr C with appropriate pressure area care and they considered the board's failing to be significant. I, therefore, upheld Mr C's complaint. I am also concerned that during their own investigation of Mr C's complaint, the board did not recognise the failings in Mr C's care and take appropriate remedial action.
Redress and Recommendations
The Ombudsman recommends that the Board:
- feed back my decision on this complaint to the staff involved;
- ensure that in future nursing staff carry out appropriate assessment and monitoring of patients at risk of developing pressure ulcers;)
- ensure that in future, staff carry out a full and proper investigation of patients' complaints and recognise failings where they exist; and
- provide Mr C with a written apology for the failings identified and offer to meet with him to discuss their learning and actions as a result of his complaint.