Poor nursing care resulted in inadequate pressure area management for terminally ill patient

What happened

A couple of days after Mr C's admission to hospital, Mr C's family noticed a pressure sore on his sacrum and asked for a referral to the tissue viability nurse. Staff ordered a pressure relieving airbed for Mr C, but this took four days to arrive. Mr C's family said that during this time, his pressure sore became much worse.

Mr C was transferred to a hospice shortly after, but died two weeks later.

Mr C's daughter complained to the Trust about the nursing care provided. She was concerned about inadequate pressure area care for her father and that there was evidence of incorrect completion of medical records. Although she understood that her father's prognosis was poor, she considered his death happened sooner than expected because of the Trust's failings.

What we found

There were failings in the nursing care given to Mr C, particularly in relation to pressure area care. Although the Trust had acknowledged some of these faults, its response did not fully address these or provide assurances that appropriate actions had been taken to learn from this complaint. The Trust also failed to explain that nursing staff were responsible for faults identified in the pressure area care and not a healthcare assistant, as it had said in its response.

The Trust's record keeping was poor, which meant that we could not be certain what impact the faults had had on Mr C's condition. This means that Mr C's family have been left not knowing whether his care detrimentally affected his condition, which has added to their distress.

Putting it right

The Trust apologised to Mr C's daughter and paid her £500 in recognition of the distress caused, which was exacerbated by its complaint handling. It also produced an action plan to address the faults we identified.