Older patient discharged with pressure sores

What happened

Mrs G went into an independent hospital for hip replacement surgery funded by the NHS. After her operation, she complained to nursing staff that her heels were sore. Her heels had been healthy before she went into hospital, and she had been independently mobile at home.

When staff discharged Mrs G several days later, she had a blister on her heel that developed into a pressure sore. She needed multiple visits from district nurses for treatment once she got home.

What we found

There were some failings in the way nurses in the hospital assessed Mrs G's skin  and in how they managed the risk. We could see no evidence that staff took or planned appropriate and timely action to try and avoid a pressure wound.

Putting it right

The Clinical Commissioning Group acknowledged and apologised for its failings and put together an action plan that showed how it had learnt from its mistakes so that they would not happen again.