Summary
The complainant (C) complained to my office about the nursing care and treatment given to their late parent (A) at home and in hospital (acute care) by Lothian NHS Board (the Board). A was an adult with multiple sclerosis (an autoimmune condition that affects the brain and/or spinal cord). Due to progression of the condition A was doubly incontinent, immobile, and unable to eat or drink independently. A required assistance daily from carers and weekly from district nurses.
A developed pressure damage to their skin whilst in the community, and they were later admitted to hospital with sepsis (overwhelming infection). A was discharged home and readmitted within a short period of time. They died shortly after their readmission to hospital.
C raised concerns that A did not receive appropriate treatment at home from the district nurses, and specifically that, pressure damage was not treated appropriately. C also raised concerns about the standard of acute nursing care specifically in relation to; pressure damage, nutrition, basic care, and record keeping.
The Board said that the district nursing team considered that they had provided reasonable nursing care to A whilst they were at home. The Board also said, acute nursing staff were made aware of A’s needs and were concerned about the integrity of A’s skin. The Board highlighted that regular drinks were offered to A, however, A declined these on occasions. It was noted that some documentation was not present in the medical records. An action plan was agreed to make improvements in staff awareness, completion of documentation, and the importance of charts.
During my investigation I sought independent clinical advice from a registered nurse with experience in both community and acute care settings and with particular knowledge of the management and treatment of pressure damage.
Having considered and accepted the advice I received I found that:
District nursing care
There was evidence of significant omissions in the care provided by the district nursing team including
- District nurses failed to update assessments accurately or in line with the minimum frequency.
- District nurses failed to check A’s skin during joint visits.
- There was a failure to plan visits with two staff members.
- District nurses showed an over reliance on A to report the condition of their own skin.
- The pressure ulcer risk assessment was not appropriately completed and updated.
- There was a failure to have a person-centred care plan in place.
Acute nursing care
There was evidence of significant omissions in the acute care provided by the Board including
- The failure to provide reasonable basic nursing care and end-of-life care.
- Nursing staff failed to create and follow a person-centred care plan.
- Nursing staff failed to carry out and record reasonable care rounding.
- Nursing staff failed to carry out relevant assessments and failed to reasonably complete appropriate charts.
- There was a failure to provide continuity of wound care treatment and follow the appropriate national guidance.
- There was a delay in referral for assessments for pressure damage and nutrition.
Taking all of the findings above into account, I upheld C’s complaints.
Recommendations
What we are asking the Board to do for C:
| Rec number. | What we found | What the organisation should do | What we need to see |
|---|---|---|---|
| 1. |
Under complaint point (a) I found that the district nursing care and treatment was unreasonable. Under complaint point (b) I found that the nursing care and treatment given to A in hospital during two admissions was unreasonable. |
Apologise to C for the failures identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies. |
A copy or record of the apology. By: 25 August 2025 |
We are asking Lothian NHS Board - Acute Services Division to improve the way they do things:
| Rec number. | What we found | What the organisation should do | What we need to see |
|---|---|---|---|
| 2. |
Under complaint point (a) I found that the district nursing team failed to
|
Patients receiving district nursing care in the community should be appropriately assessed and have appropriate care plans in place that are regularly reviewed and updated. |
Evidence that the findings of my investigation have been fed back to the district nursing team involved in a supportive manner for reflection and learning. By: 25 August 2025 Evidence the Board have taken action to ensure all staff are proficient in completing risk assessments (including Waterlow) and developing person-centred care plans. By: 24 November 2025 Evidence an independent audit of patients within the district nursing care has been completed by an independent person external to the Board with the appropriate level of expertise and experience. The purpose of the audit should be to ensure that district nursing care has been appropriately undertaken. In particular that appropriate risk assessments (including Waterlow) are in place, along with a person-centred care plan and where appropriate a wound care chart. If gaps are identified, evidence that action has been taken to rectify the situation in each case. Progress update by: 24 November 2025 Completed audit by: 23 January 2026 |
| 3. |
Under complaint point (a) I found that the district nursing team failed to plan two person visits to A after it was identified this was required to complete basic nursing care, particularly skin checks. Under complaint point (a) I found that the district nursing team relied on A to report on their own skin condition when unable to assess their own skin. |
Patients receiving district nursing care should be given basic nursing care with regular checks, such as skin checks, as required. Patients should receive safe and appropriate care from an adequate number of district nursing staff and in line with their assessed needs. Patients who are frail, immobile, experiencing deteriorating health, and who are unable to visually check, should not be expected to report on their own well-being or condition (i.e. skin health) in lieu of appropriate checks by a clinician. |
Evidence that the findings of my investigation have been fed back to the district nursing team involved in a supportive manner for reflection and learning. Evidence an independent audit has been completed as detailed in recommendation 2. Progress update by: 24 November 2025 Completed audit by: 23 January 2026 |
| 4. |
Under complaint point (b) I found that the hospital nursing team failed to
|
Patients who are admitted to hospital should be appropriately assessed and have a person-centred care plan in place. These should be reviewed regularly. |
Evidence that the findings of my investigation have been fed back to the relevant involved in a supportive manner for reflection and learning. By: 25 August 2025 Evidence an independent audit of inpatient nursing care, particularly in relation to the carrying out of nursing assessments and completion of patient paperwork/documentation. This should be carried out by a person independent to the Board with the appropriate level of expertise and experience. The purpose of the audit would be to ensure that appropriate nursing assessment and documentation is completed within the correct timescales, and that particular consideration has been given to ensure wound charts are completed as required by the Vale of Leven Enquiry recommendations 2014. Progress update by: 24 November 2025 Completed audit by: 23 January 2026 |
| 5. |
Under complaint point (b) I found that there was a delay in making appropriate referrals for specialist review of A. Specifically there was
|
Patients who require specialist review/input into their care should have referrals made without delay. |
Evidence that the findings of my investigation have been fed back to the district nursing team involved in a supportive manner for reflection and learning. Evidence that the Board have robust referral pathways in place for:
By: 23 September 2025 |
| 6. |
Under complaint point (b) I found that care and treatment provided by nursing staff was unreasonable, particularly
|
Patients who are admitted to hospital should receive reasonable basic nursing care to meet their needs. Patients with skin damage/pressure damage should receive care and treatment using appropriate and correct products that are safe for them and their condition. Patients with, or at risk of, pressure damage should receive reasonable nursing care and treatment including regular repositioning. When they are reluctant to be repositioned, they should be offered the use of turn assist equipment to help. Patients who have been admitted to hospital should have their basic nutritional and hydration needs met, particularly when, they are unable to meet their own needs independently due to their medical condition. Patients should receive appropriate support from nursing staff. |
Evidence that the findings of my investigation have been fed back to relevant staff in a supportive manner for reflection and learning. Evidence staff members are aware of formulary products for skin damage, their use and contraindications. Evidence the Board have in place a process for assessing whether pressure assist equipment is needed and that this equipment is available for use when required. By: 23 September 2025 If any gaps in care are identified by the audit (in recommendation 4), evidence that these have been addressed to avoid a similar situation happening again. By: 23 January 2026 |
Feedback
Response to SPSO investigation
In providing information in response to enquiries made by my complaints reviewer, the Board were asked to provide both clinical notes from admissions to hospital and the district nursing notes prior to admission to hospital. The district nursing notes were not provided in response to this initial enquiry.
When my complaints reviewer contacted the Board to notify them that the complaint would be investigated, they made a further specific request for district nursing notes to be provided. In response the Board provided a copy of the written ‘house’ notes from A’s home. There was no indication that any other notes were available.
Very late in my investigation the Board disclosed that there were further electronic district nursing notes held within their TRAK system. Once aware that there were further electronic notes available, my complaints reviewer requested that these be shared with us.
When we make enquiries to organisations for records relating to a complaint, and particularly in the case of medical records, we ask that all the relevant records relating to the complaint be provided. In this case, both the written and electronic district nursing notes should have been provided in response to our initial request for medical records. Not doing so extended the time taken for me to complete my investigation.
I expect all Boards to provide all the relevant information in response to my office’s initial request and I urge the Board to ensure this happens going forwards.
Points to note
- I draw the Board’s attention to the Adviser’s view that there may have been potential breaches of the NMC’s The Code. The Adviser told us that they consider there may have been breaches in: delivering the fundamentals of care, preventing ill health, working with colleagues to preserve the safety of those receiving care, identifying risks, completing records, accuracy of records, putting situations right, and escalating concerns. I strongly encourage the Board to consider this carefully, discuss with staff involved with a view to taking action or sharing a copy of this report with the NMC.
- The written house district nursing records in this case do not always match the electronic TRAK records. On occasions some information is omitted from one or the other of the records. Records both written and electronic should be an accurate, complete record of what happened during a visit to a patient. I encourage the Board to reflect on the records in this case and consider whether there is any learning in relation to record keeping for the staff involved.