Nursing staff did not monitor older patient, who then suffered a pressure sore

What happened

Mr D complained that his mother Mrs G's pressure sore could have been avoided and that ward staff failed to notice she was deteriorating while she was in hospital. Although the Trust acknowledged some failings in the care his mother received, Mr D did not believe it had done enough to improve services. He complained that the standard of care during his mother's admission caused her general deterioration, so she could not go back to her residential home and had to go into a care home.

What we found

Mrs G did not receive adequate pressure area care and this, on the balance of probabilities, led to her developing avoidable pressure sores. She suffered pain and discomfort, which could have been avoided.

Record keeping about staff assessments of Mrs G's condition was poor. As a result, we could not find out whether nursing staff should have been concerned about Mrs G before her son alerted them.

The standard of care Mrs G received was not directly responsible for her being unable to return to her residential home when she was discharged from hospital. It may have contributed to Mrs G's increased needs, but the causes of decline in an elderly patient can be complex and varied and therefore we cannot conclude Mrs G's admission to a care home could have been prevented.

Putting it right

The Trust acknowledged and apologised for its failings in relation to Mrs G's pressure care, the monitoring of her condition and the documentation about this. It also paid her £750 to recognise the avoidable pressure sores she developed.

The Trust agreed to prepare an action plan to address its failings.