Decision Report 201608302

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs B). Ms C raised concerns that Mrs B's daughter (Ms A) had not been provided appropriate care and treatment for an ulcer on her heel by practice nurses. Ms A had complex health conditions, including diabetes, and over several months practice nurses were dressing and monitoring the ulcer on her heel. The wound deteriorated and Ms A had to have an above the knee amputation as a result.

We took independent advice from a practice nurse. We found that the dressings and wound cleansing products used by the practice nurses were not in line with guidance, and that the ulcer was not assessed in line with Scottish Intercollegiate Guidelines Network guidelines. We also found that, given Ms A's other health conditions, the practice nurses should have taken steps to involve other specialisms at an earlier point. We found that it was not possible to say whether an earlier referral to a specialist would have prevented the deterioration in the wound, but we found that it would have resulted in a more controlled care experience. We also found that the practice's own complaints investigation did not identify or address the failings in the care provided to Ms A. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to take appropriate action in relation to Ms A's heel wound and for failing to identify these issues in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Practice nurses and other clinical staff within the practice should be practising in accordance with the agreed wound formulary, unless there is a clear and robust clinical reason for opting for a non-formulary product, in which case, this should be clearly documented.
• Management of diabetic foot ulcers should be carried out in accordance with Scottish Intercollegiate Guidelines Network guidelines for the management of diabetic foot ulcers.
• Expert input should always be asked for if dealing with a difficult wound that is not healing.

In relation to complaints handling, we recommended:

• The practice's complaints handling procedure should ensure that failings (and good practice) are identified, and should enable learning from complaints to inform service development and improvement.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.