Poor care for man at risk of pressure sores

What happened

Mr B had a history of Parkinson's disease and psoriasis and had a hip operation in spring 2010.

At his assessment before going into hospital, staff found that Mr B was at risk of developing pressure ulcers because he had dry and tissue paper–like skin, was a wheelchair user, elderly and had Parkinson's disease. They provided a pressure relieving mattress for him and also noticed a small sore area on his bottom that had developed before admission.

After his operation Mr B was discharged from hospital in summer 2010. Mrs B complained that her husband suffered several pressure sores and said this was due to poor nursing care. She said that as a result of this, Mr B needed to go into a nursing home and she wanted the Trust to pay for, or contribute to, the costs of the private care home she had chosen.

The Trust commissioned an independent report that found little evidence that there were firm plans in place or interventions to protect Mr B from developing a pressure injury, or guide the nurses in how to prevent further deterioration.

What we found

Although poor pressure area care may have contributed to Mr B's pressure sores, it was the overall decline of his condition that warranted his transfer to a nursing home.

The Trust had taken sufficient action to improve its service in relation to pressure area care.

Mr B needed general nursing care, rather than specialist care, and this was provided at the care home. The Trust's decision not to fund the care at the private home chosen by Mrs B was reasonable.

The complaints handling process took a long time, mainly due to the Trust's delay in clearly acknowledging the failing in care, but an independent view was provided which confirmed the failings.

We could not say for certain that Mr B would not have developed pressure sores with appropriate pressure area care. However, opportunities were missed to reduce the risk and to minimise his pain and suffering. In addition, witnessing the poor care caused Mrs B distress and the Trust had not properly acknowledged the impact of these failings on both Mr and Mrs B.

Putting it right

The Trust apologised for the poor pressure area care and paid Mrs B £1,000 in recognition of the impact of this on both her and her husband. The Trust also apologised for the poor complaint handling and paid Mrs B £750.