Bed sores occurred and developed while her father was in hospital due to poor care
14. Miss A complains that Mr A got bed sores (these are also referred to as pressure sores or pressure ulcers) on the heel and ball of his foot and his ear. She believes this happened due to poor care by the Trust.
15. The Trust said it saw Mr A within one hour of his admission to A&E and it documented he had pressure sores by that stage and raised a safeguarding concern. The Trust said the pressure sores were not hospital acquired, but community acquired as they were discovered within 72 hours of admission.
16. The Trust said the documentation was not 'brilliant' and noted multiple pressure sores were documented, but this should have included the location and details of the damage. The Trust said it was not aware of a pressure sore on Mr A's ear.
17. Miss A does not agree that Mr A’s bed sores were community acquired. She said she would have noticed if he had bed sores in the Care Home, as she provided daily care for him, including putting cream on his skin.
18. In response to our proposal to investigate, the Trust said Mr A was risk assessed for pressure sores using the Waterlow score (a tool used to assess risk of pressure sore development). The Trust said it implemented a care plan and a SSKIN bundle (used to aid care planning for patients at risk of pressure sores) was completed throughout Mr A’s admission.
19. We reviewed Mr A’s medical records and considered clinical advice to help us decide whether the pressure sores started during his hospital admission.
20. Our adviser explained that pressure sores can develop when a large amount of pressure is applied to an area of skin over a short period, or when less pressure is applied over a longer period. This pressure affects the blood supply, causing damage to the skin. Pressure sores are classified as follows, depending on the presentation and severity of the injury to the skin and/or underlying tissue: category 1-4; or unstageable and suspected deep tissue injury (SDTI).
21. On the day of Mr A’s admission to hospital on 18 September, a staff member at the Care Home completed a body map diagram and documented ‘skin intact’ and ‘no redness’. On the same day, after Mr A’s admission, a doctor documented that he had pain in his right foot, a pressure sore and ‘skin intact’. It is important to note that the skin is intact with category 1 pressure sores and SDTI. Shortly after, the staff nurse in A&E documented ‘multiple pressure sores to feet/legs including an unstageable one...’ This led the nurse to complete an incident report and safeguarding referral.
22. During Mr A’s admission, staff documented the following in relation to his pressure sores:
· 19 September: two unstageable on left inner side of foot; blisters on left heel, and the side of the big toe/foot; SDTI on left heel and side of foot (the body map diagram also included a pressure sore to the right foot)
· 20 September: SDTI on left and right heel
· 21 September: SDTI on both feet
· 22 September: SDTI on left foot/heel
23. The tissue viability nurse saw Mr A on 24 September and documented: SDTI to left bunion; pressure ulcer to right heel, unstageable to right inside ankle; and SDTI forming into unstageable to left heel.
24. On 25 September after Mr A was discharged, a staff member at the Care Home completed a body map diagram, documenting a pressure sore to his right ear and pressure sores to both feet.
25. Our adviser explained that before Mr A was admitted, there were several factors that made him vulnerable to pressure sores: his clinical condition had changed; he had developed swollen legs and feet; and his mobility was reduced from 5 September, 13 days before admission. We note that Trust staff documented pressure sores at 10.05pm and 10.55pm, which was only a few hours after his arrival. The safeguarding referral also suggests the Trust was concerned about the pressure sores Mr A had developed before his arrival to hospital. Based on this evidence in the medical records and the clinical advice, we consider it is likely pressure sores on Mr A’s feet started before his admission to hospital on 18 September. He then developed further pressure sores on his right foot.
26. We have carefully considered Miss A’s account that she would have noticed if Mr A had bed sores in the Care Home before his admission. It is possible Mr A’s pressure sores were not obvious at that stage. We have considered our adviser’s explanation that the time it takes for a pressure sore to form depends on the amount of pressure applied and how vulnerable the person’s skin is to damage. For instance, in people who are vulnerable, a category 3 pressure sore (full thickness tissue loss) can develop within only one to two hours. We appreciate it must have been upsetting for Miss A to later discover Mr A’s pressure sores.
27. There is no documentation of a pressure sore to Mr A’s ear during his admission. On 24 September the tissue viability nurse assessed Mr A and completed detailed documentation but did not make any reference to a pressure sore to the ear. The last documented skin check in hospital was at 4pm on 25 September, the day of discharge, and this also does not refer to a pressure sore to Mr A’s ear. The Care Home documented a pressure sore to Mr A’s ear at 7.30pm on the day of discharge. Our adviser explained that a pressure sore to the ear can develop very quickly as there is no fat layer and there is a lack of skin depth to cartilage. They can develop so quickly that it could have occurred during transfer from the hospital to the Care Home.
28. After considering the evidence available and the clinical advice, our view is that it is likely the pressure sore to Mr A’s ear started on 25 September, but we cannot say whether this started in hospital or during the journey to the Care Home. This means we cannot say whether it was preventable.
29. We went on to consider whether Mr A was properly assessed for his risk of pressure sores and whether these were managed appropriately. We considered clinical advice to help us decide whether the Trust followed the relevant guidance.
30. A staff member at the Trust completed a body map diagram when Mr A was admitted, documenting pressure sores on both feet. A staff member also completed a Waterlow score on admission and this identified he was at risk of pressure area damage. Our adviser noted that when the staff member calculated the Waterlow score, they did not take into account that Mr A had dementia, so his risk of pressure damage was underestimated: he scored 14, meaning at risk, when it should have been at least 18, meaning high risk.
31. The NICE guideline states patients who are at high risk of pressure ulcers should be given a skin assessment and individualised care plan. The NICE guideline also suggests heels should be elevated for patients with pressure damage to heels: ‘Discuss with adults with a heel pressure ulcer and if appropriate, their carers, a strategy to offload heel pressure as part of their individualised care plan.’
32. The Trust’s Policy for patients at high risk says the following steps should be taken:
· discuss pressure area care with patient as appropriate
· utilise dynamic pressure relieving mattress system
· keep moving patient and limit seating to less than two hours
· assess and manage incontinence and nutrition.
33. There is evidence in the medical records that the Trust used a dynamic mattress, regularly changed Mr A’s position from 2am on 19 September and managed his incontinence and nutrition.
34. Mr A had existing pressure sores on his feet when he was admitted. Despite this, there is no evidence in the medical records that his heels were elevated. We note there is reference to Mr A declining to elevate his heels, but this was only on four occasions, on 19 and 20 September. During our investigation, Miss A told us she recalls Mr A’s legs had been propped up when she visited around 23 September. However, due to the lack of information in the medical records, there is not enough evidence to assure us that the Trust consistently elevated Mr A’s heels.
35. In summary, based on what we have seen, the Trust did not correctly assess Mr A’s risk of pressure sore development and did not appropriately implement or encourage heel elevation to offload pressure from his heels. We consider there were failings by the Trust as it did not act in line with the NICE guideline or Trust Policy. We acknowledge it must be upsetting for Miss A to learn about this.
36. We considered clinical advice to help us decide the impact of the failings we have identified. We consider that Mr A’s existing pressure sores deteriorated, and he developed additional pressure sores due to the Trust’s failure to offload pressure from his heels or encourage him to do so. This may have caused Mr A mild pain and discomfort. We also appreciate that the knowledge of this will cause distress to Miss A.
37. In response to the complaint, the Trust agreed to take action to improve the recording of pressure damage in A&E.
38. The safeguarding enquiry made the following recommendations to the Trust:
· Ongoing mandatory pressure ulcer training for nursing staff including the role of consistent wound classification and documentation to ensure a uniform approach to pressure ulcer management and continuity of care
· Discharge documentation to accurately report a patient’s skin damage.
39. We note that the Care Quality Commission (CQC) completed an inspection the year after Mr A’s admission and found good practice in relation to the Trust’s use of weekly ‘harm free panels’ to reduce pressure ulcers and improve safety awareness amongst staff. The panel investigates if pressure ulcers were avoidable and what could be done to prevent pressure ulcers in the future. It also found there was a protocol in place in A&E which included information about pressure area screening.
40. After considering the outcome of the inspection by the CQC, it seems there has been some improvement in the assessment and management of pressure ulcers since Mr A’s admission. Despite this, we note the Trust has not provided any information about whether action was taken in response to the safeguarding enquiry, and we agree that further training for nursing staff would be appropriate. The Trust has also not provided an acknowledgement to Miss A of the failings we have identified during our investigation. Therefore, we recommend that the Trust takes further action and provides a financial remedy in recognition of the impact on Miss A. Our recommendations can be found at the end of this report.
Staff did not communicate with her, as her father’s power of attorney for health matters, about his bed sores and the Trust has not taken enough action to address this
41. Miss A complains that the Trust did not tell her about Mr A’s bed sores, which it should have done as he had vascular dementia and was not always cooperative.
42. In response to the complaint, the Trust acknowledged staff did not tell the family about Mr A’s pressure sores. The Trust said Mr A’s wife was noted to be his next of kin and power of attorney information was not recorded in his hospital records.
43. We considered the medical records and clinical advice to help us decide whether the Trust followed the relevant guidance on communication.
44. The Trust’s Policy for patients at high risk says, ‘discuss pressure area care with the patient as appropriate’. The NICE guideline says, ‘Discuss with adults with a heel pressure ulcer and if appropriate, their carers, a strategy to offload heel pressure as part of their individualised care plan.’ This guidance applied to Miss A, particularly as she had lasting power of attorney for health and welfare for Mr A.
45. Based on what we have seen, there is no evidence that pressure area care was discussed with Mr A or Miss A. The Trust documented the next of kin as Mr A’s wife, but the ‘Do not attempt cardiopulmonary resuscitation’ form states, ‘Discussed with daughter – power of attorney.’ This supports that the medical team knew Miss A had power of attorney, so it would have been appropriate for the Trust to communicate with her when needed. We consider there was a failing by the Trust as it did not follow the NICE guideline and the Trust Policy in relation to communication.
46. We considered clinical advice to help us decide the impact of the failing we have identified.
47. Discussing pressure area care with Miss A and Mr A would have given staff and Miss A the opportunity to encourage him to comply with care. We cannot say that discussing pressure area care would have changed the outcome. However, not doing so was a missed opportunity to have reduced the likelihood of skin damage. We also acknowledge that this caused Miss A distress as she was not prepared for the poor condition of his skin.
48. During the local complaints meeting, the Trust acknowledged that it had not communicated appropriately about Mr A’s pressure sores. The Trust agreed an action to remind staff not to assume family are aware of sores and said it was working with the relevant wards to improve communication. The Trust said staff have been reminded of the importance of communicating all information about a patient’s care to the next of kin.
49. We do not recommend that the Trust takes any further action, after considering the steps it has already taken. However, we recommend a financial remedy in recognition of the impact on Miss A. Our recommendations can be found at the end of this report.
Staff did not give her father prescribed pain relief for his bed sores and the Trust has not taken enough action to address this
50. Miss A complains that the Trust did not give Mr A pain relief, after she became aware of this during the complaints meeting. Miss A believes Mr A would have been in pain while he was in hospital.
51. In response to the complaint the Trust said pain relief was prescribed but not given to Mr A.
52. In response to our proposal to investigate, the Trust said it prescribed paracetamol and codeine to be given if needed, but it did not prescribe regular pain medication for Mr A.
53. We considered clinical advice to help us decide whether the Trust assessed and managed Mr A’s pain appropriately, in line with the relevant guidance.
54. After considering the medical records and clinical advice, we consider the Trust appropriately assessed Mr A’s pain, by scoring this using the National Early Warning Score (NEWS) chart (a tool used to detect and respond to clinical deterioration). Mr A generally scored 0 (meaning no pain) except for two occasions when he scored 1 (meaning mild pain).
55. The Trust prescribed paracetamol and codeine to Mr A, to be given as required. The Trust documented that he complained of pain in his right foot on 18 September, and he was given paracetamol. The Trust did not give Mr A any pain relief after this occasion.
56. One occasion when Mr A scored 1 on the NEWS chart was 19 September when he was in pain but declined medication. The other occasion was 20 September when he had pain in his right hip; the Trust did not give him pain relief but did arrange an X-ray the same day to rule out any bone injury. We note from the medical records there were occasions when Mr A was in pain but declined medication. There were also occasions when he was in pain, but the Trust took no action: on 22 September he complained of pain in his left foot and on 24 September he complained of pain, but it was difficult to locate.
57. Our adviser said as Mr A refused his medications, including pain relief, this should have been escalated to the prescriber. The relevant guidance is:
· the NMC guidance, ‘keep colleagues informed when you are sharing the care of individuals with other health and care professionals and staff.’
· the NMC standards, ‘You must contact the prescriber or another authorised prescriber without delay...where assessment of the patient indicates that the medicine is no longer suitable.’
58. Our adviser explained that one reason a medicine is ‘no longer suitable’ is when a patient refuses it. It may have been that Mr A refused pain relief because this was in the form of oral tablets, rather than intravenous or liquid, if he had any difficulty swallowing. The reason for refusal should be assessed and the prescriber should be informed so they can consider an alternative or stop the medication.
59. After considering the clinical advice and the relevant guidance, we consider there was a failing by the Trust to take appropriate action when Mr A refused pain relief, even though he indicated he was in pain.
60. We considered clinical advice to help us decide the impact of the failing we have identified.
61. Based on the advice received, and the evidence in the records it is unlikely Mr A was left in significant pain. His pain scores were mainly 0 and occasionally 1, which suggests he only had mild pain at the most. We hope it reassures Miss A that we have seen no evidence that Mr A was in any significant pain during his hospital admission.
62. Even though we do not consider the failing we have identified had any significant impact on Mr A, it is helpful to note that the Trust has learned from the complaint. The Trust said Mr A’s experience has been discussed with the ward managers and an action plan to improve pain control would be developed. This is in line with the Ombudsman’s ‘Principles of Good Complaint Handling’, which says good complaint handling means ‘Using all feedback and the lessons learnt from complaints to improve service design and delivery.’ We do not consider we need to make any recommendations in relation to this part of the complaint.