Hampshire Hospitals NHS Foundation Trust

7. Mr R complains about the care provided to his mother, Mrs P, between 9 and 22 August 2024. Specifically, Mr R complains:

• Mrs P developed pressure sores due to poor hygiene and poor nursing care • Mrs P’s pressure sores were not appropriately monitored or addressed • The family were not made aware of the pressure sores • The discharge summary and communication to the district nurses did not detail the pressure sores, or the equipment needed for Mrs P at her discharge

8. Mr R says the health of Mrs P (particularly her bedsores) has deteriorated because of the Trust’s lack of communication and care and now his mother requires a specific skin care routine with barrier creams and regular changing of pads. This increase in needs means a second support carer is now needed and Mrs P now requires an electric mattress to prevent further skin breakdown, which has come at an additional cost to the family. Mrs P is no longer able to sit in a chair because it is too uncomfortable, and the pressure relieving cushion that she does have is not adequate. Mr R states that his mother is bedbound which has had a massive impact on her mental and physical health and also upon the family.

9. As an outcome of the complaint, Mr R is looking for service improvements, an acknowledgement from the Trust and a financial remedy.

10. Mrs P was admitted to the Trust 9 August 2024, due to increased confusion. Mrs P had a known history of vascular dementia (a common type of dementia caused by reduced blood flow to the brain).

11. The initial nursing assessments carried out upon admission noted Mrs P had two category 2 pressure ulcers to the sacrum and buttocks. Pressure ulcers are categorised from one to four, with category one being the least severe and category four being the most severe.

12. Mr R feels that the pressure ulcers worsened due to the poor hygiene and poor care as they were not being monitored or addressed properly. He says this caused his mother’s overall health to deteriorate.

13. Mrs P was discharged home on 22 August 2024, her care was then provided by the district nurse team and by family members.

14. Mr R says the lack of care has led to his mother requiring more care, with specific skin care routine, barrier creams and regular changing of pads by a second support carer. Mrs P is no longer able to sit in a chair and is now bedbound. Mr R tells us this has had a massive impact on Mrs P’s mental and physical health.

Issue 1 – Care and treatment of bedsores

18. Mr R complains about the actions of the Trust during his mother’s stay in the hospital. He is concerned that the Trust failed to put an appropriate level of care in place for Mrs P’s bedsores and that she did not receive the appropriate treatment which led to her developing further bedsores.

19. We considered this part of the complaint with our senior nurse adviser. We have reviewed Mrs P’s medical records, and the relevant guidance within NICE CG179. The guidance recommends the following actions:

• Using a validated scale (for example, the Braden scale, the Waterlow score or the Norton risk-assessment scale) to support clinical judgement when assessing pressure ulcer risk (point 1.1.3) • Re-assessing pressure ulcer risk if there is a change in clinical status (point 1.1.4) • Developing and documenting an individualised care plan for adults who have been assessed as being at high risk of developing a pressure ulcer (point 1.3.1) • Categorising each pressure ulcer using a validated classification tool and using this to guide ongoing preventative strategies and management (point 1.4.3).

20. We have also considered NICE QS89 which says people identified as high risk of developing pressure ulcers should be provided with pressure redistribution devices. This can include specific mattresses, pressure redistribution cushions, and equipment which offload heel pressure. Clinical judgement should be used to determine which type of device a person needs.

21. The medical records show us that Mrs P’s risk of pressure ulcers was assessed on admission using a recognised and validated risk assessment tool called the Braden Scale. Mrs P’s existing pressure damage was documented within this assessment, noting that she had two grade 2 community acquired pressure ulcers to the sacrum and buttocks. A grade 2 pressure ulcer involves partial-thickness skin loss, presenting as an open or burst blister, which requires careful management to promote healing and prevent further damage.

22. Our senior nurse adviser explains that Mrs P’s total Braden score was 13, which indicates that she was at high risk of further pressure damage. Given that she was at high risk, a pressure ulcer prevention plan was put in place.

23. There is evidence that throughout Mrs P’s admission her skin was regularly checked and that its condition was documented. We have also seen evidence that Mrs P was nursed on a pressure redistributing device and was re-positioned regularly. We note that by 16 August 2024, Mrs P’s community acquired pressure ulcers were healed and within the records it is detailed that upon discharge, the pressure areas were ‘red and vulnerable but intact’.

24. Overall, we consider there are indications that the monitoring and treatment of Mrs P’s community acquired pressure ulcers to her sacrum were managed in line with NICE CG179 and NICE QS 89 as detailed above. The risk of developing further pressure ulcers was assessed and prevented, and the nursing care provided allowed for the pressure ulcers to heal.

25. We acknowledge that in the Trust’s response from the 28 October 2024, it apologised that Mrs P had developed a pressure ulcer while under its care. However the medical notes show that Mrs P already had this pressure ulcer upon admission, and we have not identified any indications of new pressure ulcer’s developing whilst Mrs P was an inpatient. We hope this is reassuring for Mr R and his family.

Issue 2 – Communication of pressure sores to district nursing and the family

26. Mr R complains that when Mrs P was discharged from hospital, Mrs P’s family were not made aware of the presence of her pressure ulcers. He also complains about the standard of communication with the district nurses, as they were not informed of the pressure ulcers, nor of the equipment Mrs P required at home to continue with her care. Mr R says this lack of communication has led to Mrs P requiring an increased level of care at home.

27. We considered this part of the complaint with our senior nurse adviser. We have reviewed Mrs P’s medical records, and we have considered the relevant guidance outlined in the NMC’s standards of proficiency and the NMC’s Code of professional standards of practice and behaviour.

28. The NMC’s standards of proficiency say nurses should provide information and explanations to people, families and carers and respond to questions about their treatment and care and possible ways of preventing ill health to enhance understanding (point 2.8).

29. The NMC’s Code says nurses must maintain effective communication with colleagues, which includes keeping them informed when sharing the care of individuals with other health and care professionals and staff (points 8.2 and 8.3). They must also work with colleagues to preserve the safety of those receiving care, which includes sharing information to identify and reduce risk (points 8.5 and 8.6).

30. In the Trusts response from 28 October 2024, it states ‘X is very sorry that the ward did not communicate to yourselves as a family that your mother had developed pressure ulcers whilst admitted as an inpatient on X ward. X is also disappointed that the team did not take full actions necessary on discharge to inform the district nurse team of this pressure damage and to ensure that the appropriate mattress was sourced for your mother’.

31. In our review of the medical records with our nursing adviser, we can see that Mrs P already had an electric bed with an air mattress in place prior to her admission. During the admission, the Trust’s frailty team confirmed all relevant equipment was already in place. We can also see the community occupational therapist had ordered a “hi-low profiling bed with bed rails” and a “reclining in-situ hoist sling”.

32. For this reason, we consider there are no indications any additional equipment needed ordering as it appears to have already been in place prior to the admission.

33. With regards to the communication of Mrs P’s pressure areas, in line with the NMC guidance outlined above, we consider the family and the district nursing team should have been informed of their condition. Our adviser explained that it is expected that upon discharge the district nursing referral will include details of vulnerable pressure areas. The Trust has acknowledged this was not done.

34. For this reason, we consider there are indications of service failure with regards to the Trust’s communication with the district nurses and Mrs P’s family regarding Mrs P’s pressure ulcers.

35. We have considered whether there are indications the lack of communication had an impact on Mrs P that has not yet been put right by the Trust.

36. We understand that if the Trust had communicated the presence of Mrs P’s vulnerable pressure areas to the district nursing team, it would have made them aware at the point of discharge that they needed to continue to provide preventative care to Mrs P and monitor her for signs of deterioration.

37. However, we consider this would not have had an impact on Mrs P’s care, as it is expected that the district nurses would do their own skin assessment when they visited Mrs P after her discharge and put a care plan into place for ongoing monitoring and management.

38. We have also identified that prior to this hospital admission, Mrs P had category two pressure ulcers and was bedbound. She had a live in carer and a ‘four times a day’ package of care. This means she already had the appropriate support and equipment in place to manage her vulnerable pressure areas upon discharge, and so the omission of information in the district nursing referral would not have changed this.

39. In conclusion, we consider there are no indications the omission in communication has had any negative impact on Mrs P’s care. Despite this, we recognise that this omission likely caused some concern for Mr R.

40. We can see from the Trust’s response it has provided an apology to him for the omission in communication and the impact this had. The Trust has also advised that additional training has been provided to the ward staff relating to the fundamentals of care, discharge planning, and referrals to community partners. We consider this response is in line with the NHS Complaint Standards with regards to giving fair and accountable responses and promoting a learning culture.

41. For this reason, we consider the Trust has already done enough to put right the impact of what went wrong, and we will not be taking any further action on this part of the complaint.

1. We have carefully considered Mr R’s complaint about Hampshire Hospitals NHS Foundation Trust (the Trust). We were sorry to learn how Mr R and his mother, Mrs P, were affected by the concerns raised. It was evident this was a difficult time for the family.

2. We have reviewed the information provided by Mr R and the Trust. We have also considered Mrs P’s medical records for the period of time relevant to the complaint, as well as seeking advice from a senior nurse adviser. We took this into consideration alongside the guidance and policies relevant to the care of Mrs P.

3. After doing so, we did not identify indications of service failure in relation to the treatment and care of Mrs P’s bed sores. However, we have identified indications of service failure in relation to the Trust’s communication of Mrs P’s bedsores with her family and the district nursing team. We have not identified any indications this had a negative impact on Mrs P’s care, however, we recognise this likely caused a level of concern for Mr R.

4. We can see the Trust has acknowledged and apologised for the lack of communication with the family and the district nurses. It has also put measures in place to ensure further training and support is delivered to the relevant staff. Further to this, the Trust instigated a new process to ensure nurses complete a check list when discharging patients.

5. We consider the actions taken by the Trust in response to the complaint are in line with the NHS complaint standards with regards to giving a fair and accountable response by providing an apology for the lack of communication and putting service improvements in place.

6. We will explain the reasons for our decision in this statement. Complaints give us a valuable insight into the organisations we investigate so we would like to thank Mr R for sharing her experiences with us. It is important to acknowledge that where we have not identifies any indications something went wrong in relation to the concerns Mr P raised, it does not detract from Mr R and Mrs P’s experience, nor the impact it had on the family.