Staff were aware that Mrs F had developed a red area of skin on her bottom while she was in hospital. However, they did not tell the district nurses about this when Mrs F was discharged. Less than 24 hours after discharge, this turned into a pressure sore.
What happened
During an inpatient stay, Mrs F developed a red area of skin on her bottom that was at risk of becoming a pressure sore. Staff treated and monitored the area during admission. When Mrs F was due to be discharged from hospital into the care of the district nurses, staff sent a transfer form. However, the form did not refer to the red area of skin.
What we found
The red area should have been noted on the transfer of nursing care form in order to highlight this problem to the district nurses.
We partly upheld the complaint because the Trust did not acknowledge this in its response and this was a failing. However, in Mrs F's case, this failing did not have an impact. Highlighting the red area on the form would not have prompted an urgent visit from the district nurses and Mrs F developed the pressure sore less than 24 hours after discharge.
Putting it right
The Trust apologised to Mrs F's son.
Dorset County Hospital NHS Foundation Trust
Dorset
Not applicable
Apology