Family not told about elderly patient's bed sores

What happened

Mrs F, who was in her eighties and lived at home with her family, was admitted to hospital with breathing difficulties related to a lung condition. She was discharged three weeks later and her family found she had pressure sores and was generally very unwell. Mrs F's family and her carers were concerned at this and arranged for her to be admitted to a local community hospital. She was diagnosed with a urine infection and died two days later.

What we found

Although the Trust initially assessed Mrs F's risk of developing pressure sores and took some appropriate action to minimise this, there were failings in Mrs F's ongoing pressure area management. The record keeping was inadequate, the family were not told that Mrs F had developed a pressure sore as they should have been, and a referral was not made to the district nursing service, so that the necessary pressure area care could be continued at home.

We saw no evidence that Mrs F had a urine infection on discharge from hospital. However, we could not rule this out as there was insufficient record keeping about her condition on the day of discharge. There was no management plan in place to make sure Mrs F could urinate before leaving hospital, and after she had her catheter removed.

Mrs F's nutritional needs were managed appropriately but there was an insufficient record of her fluid intake.

The record keeping was so poor that we were unable to say if Mrs F was well enough to be discharged from hospital. However, we did not conclude Mrs F's death would have been avoided had she remained in hospital.

Putting it right

The Trust acknowledged and apologised for the failings and the upset caused to the family. We asked the Trust to produce an action plan to explain how it would address the failings we found.