Poor nursing care in the community

What happened

Mr B complained to the Trust on behalf of his mother Mrs B, who was in her eighties, about the district nursing care she received over a two-month period in autumn 2013, for an ulcer on her leg.

Mr B said that he was concerned the nurses did not care for his mother properly. He also said they did not notice or treat an ulcer that had developed on her other leg during this time.

He complained to the Trust and said it did not fully recognise the pain and suffering his mother experienced. The Trust said that it had made improvements to the service as a result of his complaint, but Mr B was still unhappy about his mother's care. Mrs B died early the next year.

Mr B said the Trust continued not to recognise the anguish both he and his mother experienced as a result of its poor care and treatment, so he brought the complaint to us.

What we found

When Mr B complained to the Trust it held a local resolution meeting and admitted to many failings. These included the way Mrs B's care was co-ordinated, that procedures were not followed, and that it had not identified the complexity of Mrs B's needs. It apologised for these failings and put action plans in place so that it could learn from these mistakes.

However, we identified more significant failings in basic nursing care that it had not previously addressed: in wound care management, pain assessment, record keeping, and communication with Mr B and his mother. Therefore, the improvements the Trust had made had not gone far enough.

The Trust's lack of good record keeping left Mr B without clear explanations for what happened, and its lack of communication caused Mr B and his mother unnecessary worry, reducing their confidence in the district nursing team.

Putting it right

The Trust acknowledged the failings we found, apologised to Mr B, and paid him £500 in recognition of the anguish and distress these events had caused him and his mother.

The Trust produced an action plan to make sure that it learned from the failings in basic nursing care. This included a review of its own wound assessment policy with a reference to national guidance. It also prepared an action plan to improve its record keeping. The Trust did this work as well as the improvements it had already made following Mr B's original complaint.