Decision Report 201708023

  • Case ref:
  • Date:
    May 2019
  • Body:
    Lanarkshire NHS Board
  • Sector:
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis


Mr C complained about the physiotherapy treatment (the treatment of disease, injury or deformity using physical methods such as massage, heat treatment, and exercise) given to his wife (Mrs A) after her hip operation at University Hospital Hairmyres. Mr C also complained that the board had failed to communicate reasonably with himself and Mrs A about Mrs A's rehabilitation potential.

We took independent advice from a senior physiotherapist. We found that Mrs A had been provided with reasonable physiotherapy. The advice we received from the senior physiotherapist was that there were two treating physiotherapists which was excellent practice. We also found that the decision not to provide physiotherapy following discharge had been reasonable and that the communication about Mrs A's rehabilitation potential had been reasonable. Therefore, we did not uphold these aspects of Mr C's complaint.

Mr C also complained about the pressure area care given to Mrs A. We took independent advice from a nursing adviser. We found that the pressure area care given to Mrs A was unreasonable. In particular, that there was a lack of risk prevention strategies implemented when Mrs A was admitted to reduce her risk of developing pressure damage; when the first damage to Mrs A's skin was identified no care plan was put in place to reduce further risk of damage; and when Mrs A's ulcer developed into a grade three pressure ulcer (grade four is the highest form of damage) the relevant guidance was not followed. We also found that the nursing communication with Mr C had been unreasonable and that there was no evidence of a care plan being initiated to address Mrs A's weight loss. We also noted that that the nursing records were unreasonable Therefore, we upheld this aspect of Mr C's complaint.


What we asked the organisation to do in this case:

  • Apologise to Mr C and Mrs A for the failings identified in pressure area care. The apology should meet the standards set out in the SPSO guidelines on apologyavailable at

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

  • Nursing staff should ensure risk assessments for pressure ulcer prevention are accurate. SSKIN care bundles should be followed appropriately to reduce the risk of a patient developing a pressure ulcer.
  • Patients with pressure ulcers should have an individualised care plan implemented to further reduce risk of deterioration to the skin.
  • Nursing staff should ensure the Healthcare Improvement Scotland standard for prevention and management of pressure ulcers is followed.
  • Ensure that there is appropriate communication with patients and/or their families during a patient's stay in hospital.
  • Patients with a pressure ulcer should have appropriate nutritional assessments undertaken and receive effective nutritional care, which is in line with relevant guidance.
  • Accurate records should be maintained in line with Nursing and Midwifery Council code of record-keeping.

Updated: May 22, 2019