Kent Community Health NHS Foundation Trust

3. Mrs D complains on behalf of her family about an aspect of the care community nurses gave her mother, Mrs Y, between 2 March and 11 April 2021. She specifically complains about the way nurses monitored and cared for a pressure ulcer on her mother’s lower back. Mrs D believes a deterioration in her mother’s health, and her death a few months later, could have been avoided.

4. Mrs D wants the Trust to accept its failings and apologise for the impact they had. She wants it to make sure other patients and families do not have the same experience. She also wants financial compensation, but this is not the main reason for her complaint.

5. Mrs Y (who was in her eighties at the time of the events we investigated) had a history of stroke and atrial fibrillation (a fast, irregular heart rate). On 19 January 2021 she was seen at her local hospital after a fall at home. Doctors treated her for low blood pressure before discharging her to her GP’s care on 2 March.

6. When she left hospital Mrs Y had a grade two pressure ulcer on her lower back (sacrum), which meant skin loss and damage had left the ulcer as a shallow open wound. Trust community nurses who cared for Mrs Y at home visited regularly over the following weeks and noted the wound had slowly deteriorated.

7. On 11 April 2021 Mrs D found her mother distressed and with a high temperature. She called an ambulance and paramedics took Mrs Y to hospital. By this time the pressure ulcer on her back had got a lot worse. Doctors treated Mrs Y for sepsis (a severe reaction to infection) and discharged her to a care home on 27 April.

8. Mrs D complained to the Trust in April 2021 and had meetings with Trust clinicians. The Trust issued its final response to her complaint in August 2021.

9. Sadly, Mrs Y died from frailty (a condition when someone is less able to recover from illness) in September 2021.

12. Mrs D believes the community nurses who cared for her mother allowed the pressure ulcer on her back to deteriorate and this could have been avoided.

13. The NICE guideline sets out how healthcare professionals, including nurses, should manage pressure ulcers. It says they should check the skin of adults at high risk of developing pressure ulcers and advise them to change position regularly (at least every four hours). Healthcare professionals should offer to help those who are unable to move themselves, using appropriate equipment if needed.

14. The pressure ulcer guideline says healthcare professionals could use a barrier preparation (such as a cream or ointment) to protect adults at high risk of skin damage from moisture or incontinence. They should also consider using special dressings to help heal more serious pressure ulcers. If a patient has a pressure ulcer on their heel, healthcare professionals should talk to them, their family and carers about how to relieve pressure on this area.

15. Mrs Y’s clinical records show there was damage to her sacrum before the community nurses got involved in her care. The nurses assessed this as a grade two pressure ulcer with ‘friable granulation’. This means new tissue had formed on the wound, showing it was healing, but the ulcer bled very easily under gentle examination and so was at risk of further damage.

16. Our nursing adviser noted Mrs Y had developed a deep tissue injury (DTI) to her sacrum by the time she went back to hospital on 11 April 2021. A DTI is a full-thickness pressure ulcer, meaning the injury goes to deeper structures under the skin. It looks like a bruise. The nursing adviser said a photograph nurses took on 1 April showed Mrs Y had purple areas of skin and open shallow wounds, indicating a DTI and a grade two pressure ulcer.

17. The nursing adviser said the skin discoloration showed the DTI had been there for some time. They usually turn black after about five days and will get worse until all the damaged tissue has gone and good tissue is exposed. This is inevitable even if appropriate equipment and wound care products are used.

18. The records also show Mrs Y developed a DTI on her right foot. This remained intact throughout the period we are investigating.

19. The records show Mrs Y used a hospital bed with a pressure-relieving mattress. The community nurses initially assessed her twice a week and then every other day from 30 March 2021. Carers visited Mrs Y four times a day to look after her hygiene and change her position, but they could not move her from side to side because of her stroke history. Nurses tried to use booties to take the pressure off Mrs Y’s heels but she would not wear them.

20. On 1 April 2021 the community nurses referred Mrs Y to a tissue viability nurse specialising in wounds that take a long time to heal. The community nurses also used a barrier preparation to protect Mrs Y’s skin from moisture. They tried to use pillows to relieve pressure on her lower back and heels. On one occasion they asked Mrs Y’s carers to do the same. They used wound dressings to encourage healing.

21. Twice in early March 2021 the community nurses told Mrs Y’s GP her health seemed to be deteriorating. She was distressed when changing position and reluctant to wear booties. Physiotherapists felt she should not be moved out of bed.

22. On 8 April 2021 the community nurses noted Mrs Y’s carers had not completed all her personal care. The nurses found dried faeces on Mrs Y’s skin and bedding. They cleaned her and told her family. On 10 April the nurses again found faeces around the pressure ulcer dressings. Our nursing adviser told us this could have contributed to the wound getting infected. It does not indicate any failings by the community nurses.

23. We can see the community nurses assessed the risk of pressure area damage. They gave appropriate advice to Mrs Y’s carers and used suitable equipment, preparations and dressings. They cleaned and dressed the wounds appropriately. They tried to reduce the pressure on Mrs Y’s heels but this was difficult because she would not wear booties. Instead they used creams to protect her skin.

24. We recognise Mrs D believes the nurses could have done more. Our nursing adviser told us the main reason Mrs Y’s pressure ulcers got worse was because she was often lying directly on her lower back and heels. Mrs D says she, other family members and the carers ‘tilted’ her mother at least four times a day and ‘at not stage was she constantly laying on the pressure sore all day’. We have no reason to dispute Mrs D’s recollection, but the clinical records show her mother’s pressure ulcers got worse despite any positional changes. We can see nurses advised the carers and Mrs Y’s family on the importance of trying to reduce pressure on damaged areas.

25. We understand how upsetting it would have been for Mrs D and her family to see the deterioration in her mother’s health and to know the pressure ulcer on her back progressively worsened from 2 March 2021 onwards. Sadly, the nurses could not have done anything more to prevent these problems. We find the nurses followed the NICE pressure ulcer guideline.

26. We do not uphold Mrs D’s complaint.

1. The Parliamentary and Health Service Ombudsman has considered Mrs D’s complaint about the care Kent Community Health NHS Foundation Trust (the Trust) community nurses gave her mother for pressure ulcers (bedsores), which she believes contributed to her mother’s death. We can see how devastating these events have been for Mrs D and we offer our sincere condolences for her loss.

2. We find the community nurses followed the relevant guidance in providing the care Mrs D complains about. This means we do not conclude the decline in her mother’s health happened because of failings in nursing care and so we do not ask the Trust to take any action.