Failings in care and treatment of a paralysed man in his eighties did not contribute to a stroke, but caused distress to his family

What happened

Mr L was paralysed with no sensation from the chest down following a spinal injury. He needed full care in all aspects of his life. He had a rare medical condition that put him at risk of a stroke as a result of uncontrolled blood pressure. Among other things, this meant that he needed special bowel and pressure area care. He also had a urinary catheter. He had pressure ulcers on his lower back, buttocks and heel.

Mr L was admitted to the Trust after several days of feeling unwell, and with blood in his urine and faeces. Nurses assessed that he was at high risk of developing pressure ulcers and documented a care plan, which included nursing him on an air mattress and turning him regularly. They identified that he was at low risk of malnutrition and initially assessed that he needed four–hourly observations of vital signs, including blood pressure. Subsequently, nurses identified that Mr L needed hourly observations in line with Trust policy.

A doctor made a provisional diagnosis of urinary tract infection and acute kidney injury caused by sepsis (a life–threatening infection) and dehydration. The management plan included various investigations, intravenous fluids and antibiotics, and changing the catheter after the first dose of antibiotics. During his admission, Mr L developed pressure ulcers. An air mattress finally arrived the day before he was discharged.

Mr L was discharged after a few days at Mrs J's request because she was unhappy about the care and treatment her father was receiving. At the time of discharge, Mr L had delirium. Mr L had a stroke soon after and died the following month.

What we found

We partly upheld this complaint. Nurses did not act in line with the applicable guidance or established good practice in respect of Mr L's pressure area care, the monitoring of his blood pressure, bowel care and catheter care.

Nurses underestimated Mr L's risk of pressure ulcers and failed to start a wound chart to give a baseline against which they could measure any improvement or deterioration in the pressure ulcers. Nurses wrongly assessed that Mr L was at low risk of malnutrition (a risk factor for developing pressure ulcers) and should have referred Mr L to a dietician but did not do so. There was insufficient evidence of regular turning, and nurses also failed to make sure that an air mattress arrived in good time.

There were failings in how Mr L's blood pressure was monitored, and nurses did not call a doctor as instructed when his blood pressure rose. Nurses failed to give Mr L the bowel care he needed and did not change Mr L's catheter in accordance with the medical plan. This put him at risk of further infection. They also did not accurately record the intravenous fluids and antibiotics.

The medical care Mr L received in respect of his acute kidney injury and infection was in line with established good practice. On balance, it was acceptable to discharge Mr L without identifying the cause of his delirium. Some doctors got it right with regard to the management of Mr L's medical condition and associated risks. However, the failure to ensure that Mr L had appropriate bowel care, was, on its own, so far below the applicable guidance and established good practice that it was service failure.

Given the medical advice we received, we could not say that Mr L's stroke was caused by any of the Trust's failings. However, it was inevitable that the delay in providing an air mattress would result in pressure ulcers developing. Also, the failings in pressure area care, and the knowledge that Mr L was not given the care he needed, caused Mrs J considerable distress. This was an injustice.

Putting it right

The Trust acknowledged and apologised for its failings and put together an action plan that showed learning from its mistakes so that they would not happen again. It also paid Mrs J £750 to acknowledge the impact these failings had had on her.