Mrs C was admitted to hospital with an existing wound to her leg. Her daughter complained that by the time she was discharged she had a pressure sore ulcer and a further injury to her left leg caused by a hot drink.
What happened
When Mrs C arrived at hospital she was assessed as having one existing injury on her thigh and a red sacrum. Six hours later staff recorded that all of Mrs C's pressure areas had been checked and were intact; however, this does not agree with the first assessment. Four hours after that, staff recorded the details of Mrs C's wounds. At this time, staff noted an additional wound.
What we found
Given the differences in the records, there are two possibilities for what happened. Either Mrs C was not thoroughly assessed when she was first admitted, or she suffered a further leg injury sometime between her admission and 11.30pm. This had not been accepted or explained by the Trust.
There was no wound care chart or care plan in Mrs C's records. Also, although the first assessment noted that Mrs C had a red sacrum, there is no further record of this. There is no evidence that Mrs C received appropriate pressure care.
Putting it right
The Trust apologised to Mrs C for the faults that we found and paid her £500 in recognition of the pain and distress she has experienced.
It also produced plans to prevent the same failings happening again.
Barking, Havering and Redbridge University Hospitals NHS Trust
Essex
Not applicable
Apology
Compensation for non-financial loss
Recommendation to learn lessons or draw up an action plan