The complainant (C) complained to my office about the care and treatment provided to their late adult child (A) by Lothian NHS Board – Acute Division (the Board).
A was in their thirties and suffered from a number of chronic illnesses and very poor health. A had regular admissions to hospital and received treatment from community and district nurses between admissions to hospital.
A was admitted to the Royal Infirmary of Edinburgh (the hospital) on 6 June 2021 with shortness of breath. A’s pre-existing leg wounds were treated in hospital during their admissions. A was discharged home on 24 June 2021. A continued to receive treatment at home from district nurses for their leg wounds.
A’s condition deteriorated and they were admitted to hospital again on 26 August 2021. A’s health continued to deteriorate, and A underwent a right knee amputation on 2 September 2021. A did not make a full recovery following surgery. A remained in hospital and suffered a cardiac arrest on 11 October 2021. Sadly, A died the same day.
C complained that A’s wounds were not appropriately assessed or treated during their admission to hospital, or during the time they were cared for at home.
In their complaint response the Board said that throughout A’s care, where infection was suspected by the district nursing team, appropriate treatment was provided. During the course of treatment at home by district nurses, A’s care plan was reviewed regularly, changes were made to the wound care plan when necessary, dressings were changed when appropriate and a referral made to the tissue viability service.
In response to our enquiries the Board said that there was evidence of good practice during A’s admission to hospital in June 2021 with respect to the management of A’s wounds. The Board acknowledged a wound care chart was not completed on the day of admission, but there were clear entries thereafter evidencing A’s wound care.
With respect to A’s admission to hospital in August 2021, the Board said that A’s wound care was appropriately documented and that available records evidenced appropriate nursing care during A’s admission.
During my investigation I took independent advice from a registered nurse. Having considered and accepted the advice I received, I found that:
Care at home
- There was no evidence of appropriate wound assessments having been undertaken whilst A was treated by district nurses for their wounds.
- The choice of dressings was on occasion unreasonable and inappropriate to manage A’s wounds.
- Whilst there were occasions where the frequency of dressing changes was stepped-up to daily changes, these were inconsistent. As a result A was left with wet and foul smelling dressings, which is unreasonable.
- There was an unreasonable delay in seeking specialist wound care when it was clear A’s wounds were deteriorating.
Care during hospital admissions
- During both admissions A’s wounds were not appropriately assessed and there were a number of instances of inappropriate and unreasonable wound care provided to A.
- During A’s June 2021 admission to hospital there was an unreasonable failure to update their wound management plan and appropriately assess a deep abscess.
- During the admission from August 2021, inadine dressings were inappropriately prescribed and applied.
- Negative Pressure Wound Therapy (NPWT, a device to promote wound healing) was used on A’s wounds without evidence of the appropriate assessments having been carried out prior to its use. NPWT was applied in circumstances where it was contraindicated. Its use was unreasonable.
- Clinicians and nursing staff did not appear to have the requisite knowledge in relation to the application of NPWT.
Taking all of the above into account, I upheld C’s complaints
Recommendations
What we are asking Lothian NHS Board - Acute Division to do for the complainant
| Rec. number |
What we found |
What the organisation should do |
What we need to see |
| 1. |
In relation to (a) and (b) I found that:
- A’s wounds were not appropriately assessed
- The frequency of dressing changes was not sufficient to manage A’s wounds
- There were missed opportunities to refer A to the Tissue Viability Specialists, and that there was an unreasonable delay in making the referral
- Dressings applied to A’s wounds were at times contraindicated or inappropriate to manage their wounds
- Negative Pressure Wound Therapy was inappropriately and unreasonably applied to an actively bleeding wound and
- Negative Pressure Wound Therapy was also inappropriately and unreasonably applied to a sloughy wound.
|
Apologise to C for the failures identified in my decision.
The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflet.
|
A copy or record of the apology.
By: 19 February 2025.
|
What we are asking Lothian NHS Board - Acute Division to improve the way they do things
| Rec. number |
What we found |
Outcome needed |
What we need to see |
| 2. |
A’s wounds were not appropriately assessed. |
Wound assessments for patients should be completed holistically and on a timely basis in line with the patient’s presentation. Assessments should appropriately document the progression/ deterioration of a patient’s wound and prescribe appropriate wound management. |
Evidence that the Board have shared the decision with all staff involved with wound care in a supportive manner for reflection and learning.
By: 19 February 2025.
Evidence that the Board have reviewed their wound management guidance to ensure it appropriately takes into account relevant national guidance with details of how any changes will be disseminated to staff.
Evidence that the Board have reviewed their wound care assessment training for relevant nursing staff in light of the findings of this investigation with details of how it will be rolled out to relevant staff.
By: 16 April 2025
|
| 3. |
The frequency of dressing changes was not sufficient to manage A’s wounds. On one occasion hospital at home staff attending A inappropriately left wet and soaked through dressings for district nursing staff to change which was unreasonable, and
Dressings applied to A’s wounds were at times not appropriate, contraindicated, or inappropriate to manage their wounds.
|
Wound dressings should be changed frequently enough to manage the level of exudate, to prevent ‘strikethrough’ and foul smells. Patients should not be left at home with wet or soaked through dressings unchanged. |
Evidence that the Board have shared the decision with all relevant staff involved with wound care assessment in a supportive manner for reflection and learning.
By: 19 February 2025.
Evidence that the Board has ensured that staff delivering such services have received the appropriate training and ongoing professional development.
This should include details of future plans to either / both provide training now and how expertise will be maintained.
By: 16 April 2025
|
| 4. |
There was an unreasonable delay in referring A to Tissue Viability Specialists and there was an unreasonable delay in making the referral. |
Where a patient’s wounds deteriorate despite on-going treatment or are non-progressing over a period of time, nursing staff should consider immediate referral for specialist tissue viability assessment.
Decisions in relation to referral should be documented and if the need for referral is identified this should be actioned without delay.
|
Evidence that The Board have shared the decision with relevant nursing staff involved with wound care in a supportive manner for reflection and learning.
By: 19 February 2025.
Evidence that the Board have an appropriate referral pathway for specialist wound management and that relevant nursing staff are aware of how to access it to make a referral.
By: 16 April 2025.
|
| 5. |
Negative Pressure Wound Therapy was inappropriately applied to an actively bleeding wound.
Negative Pressure Wound Therapy was also inappropriately applied to a sloughy wound.
|
Negative Pressure Wound Therapy should be applied in accordance with manufacturers guidance and in accordance with Board policy and HIS guidance. |
Evidence that the Board have shared the decision with all relevant staff involved in wound management.
By: 19 February 2025.
Evidence that relevant staff are aware of the Board’s policy on the use of Negative Pressure Wound Therapy and manufacturers guidelines, and
that medical staff deemed competent in prescribing/applying Negative Pressure Wound Therapy have received training in its use.
By: 16 April 2025
|
Feedback
Points to note
The ‘house held’ records which contain the written record of care provided at A’s home have been reported as lost. I encourage the Board to reflect on the circumstances leading to their loss, and whether there is any learning for them in relation to record keeping and records management policies and staff guidance.