The Ombudsman's final decision:
Summary: Meadowfield House Home for Older People and Lancashire and South Cumbria NHS Foundation Trust jointly contributed to Mrs Y’s worsening pressure sore. That caused her pain and distress. They have agreed to apologise, make service improvements and pay a financial remedy to Mrs Y and her husband.
- Mr Y complains about the care and support his wife, Mrs Y, received from Lancashire and South Cumbria NHS Foundation Trust (the Trust) and Meadowfield House Home for Older People (Meadowfield House), which was jointly funded by Lancashire County Council (the Council) and a local clinical commissioning group.
- Specifically, he complains about the Trust’s district nurses care and support in February and March 2020 at Mrs Y’s home and at Meadowfield House. He says Mrs Y developed two severe pressure sores because of poor care by district nurses and Meadowfield House staff. Mr Y says his wife has suffered severe pain and distress because of the pressure sores, which have still not healed.
- Mr Y says Meadowfield House lost Mrs Y’s paracetamol, and staff did not always provide pain relief. That caused Mrs Y unnecessary pain.
- Mr Y also complains about Meadowfield House’s cold and unsatisfactory meals, poor maintenance of her room, and a language barrier with staff.
- Mr Y says events have been upsetting for him and have placed added stress on him as his wife’s main carer.
- Mr Y would like the organisations to recognise its inadequate care, apologise and to improve its services to ensure similar fault does not happen to others. He would also like a financial payment to recognise their injustice.
What I have investigated
- I have investigated Mr Y’s complaints about Mrs Y’s pressure sores and missing paracetamol. The final section of this statement contains my reasons for not investigating the complaint in paragraph four.
The Ombudsmen’s role and powers
- The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
- The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
- If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
- The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.
- When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened.
- If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)
How I considered this complaint
- I read the papers submitted by Mr Y and we discussed the complaint with him. I considered the organisations comments about the complaint and the supporting documents they provided. I also sought independent clinical advice from a nurse.
- Mr and Mrs Y and the organisations had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
What I found
Mrs Y’s pressure sores
- Mrs Y had total knee replacement surgery in February 2020. After surgery, Meadowfield House assessed her for rehabilitation. It decided it did not have the staff availability to support Mrs Y because she needed two carers to transfer.
- On 21 February, the Trust decided Mrs Y could return home while she waited until staff were available to support her at Meadowfield House.
- Four days later, a district nurse for the Trust assessed Mrs Y at home. The district nurse planned to assess, measure and document her surgical wound in a care plan, dress the wound and carry out fortnightly visits. The district nurse noted Mrs Y’s Waterlow score was 18 (a high-risk of developing pressure sores) and provided Mr Y with a leaflet called ‘React to Red’. That leaflet provided advice and support to reduce the risk of developing pressure sores.
- On 2 March, an occupational therapist for the Council reviewed Mrs Y’s mobility. The occupational therapist decided Mrs Y could transfer with the support of one carer. A week later, the Council asked Meadowfield House to review Mrs Y’s referral now that she only needed one person to transfer.
- Meadowfield Hose reviewed Mrs Y again and admitted her on 12 March. On admission, Meadowfield House recorded that Mrs Y did not have any skin conditions and could transfer in and out of bed. There was no plan to reposition Mrs Y in bed, which had a pressure relieving mattress. However, she had bruising on her buttocks, so referred her to the district nurse service.
- The next day, a district nurse reviewed Mrs Y. They completed a risk and skin assessment, noting Mrs Y’s vulnerable areas, including sacrum (the bottom of the spine) and hips. The district nurse noted Mrs Y had been on her back since she had arrived. The district nurse advised Meadowfield House staff to reposition Mrs Y every two hours, and to offload Mrs Y’s heels. Mrs Y’s Waterlow score increased to 22.
- On 14 March, Meadowfield House referred Mrs Y to the district nurse service again. Two days later, a district nurse reviewed Mrs Y. They noticed Mrs Y had developed moisture damage to her sacrum and advised staff again to offload Mrs Y’s heels. Mrs Y’s Waterlow score remained at 22. Later that day, Mrs Y self‑discharged home.
- A district nurse reviewed Mrs Y at home on 18 March. They provided support for the moisture damage on her sacrum and referred her for an assessment by an occupational therapist. Mrs Y had no carers to support her, and Mr Y was ‘providing all care’. Two days later, the district nurse started to apply barrier cream to Mrs Y’s sacrum.
- On 21 March, the district nurse noted Mrs Y’s sacrum had worsened to Grade 4. She had also developed another Grade 4 pressure sore, including bruising, on her hip. The district nurse advised Mr Y to relieve the pressure off Mrs Y’s hip every two hours. Mrs Y’s Waterlow score increased to 24. Over a month later, a district nurse reviewed Mrs Y. Mrs Y’s sacrum reduced to Grade 3, and the hip was ungradable. Her Waterlow score increased to 29. District nurses supported Mrs Y weekly afterwards.
- On 10 April, the Trust’s occupational therapist decided the only option for Mrs Y was a hospital style bed with pressure relieving mattress. That would be instead of her king size bed because her room could not fit a second bed.
Relevant law and guidance
- The term ‘rehabilitation’ is sometimes used to describe a particular type of service designed to help a person regain or re-learn some capabilities where these capabilities have been lost due to illness or disease. Rehabilitation services can include provisions that help people attain independence and remain or return to their home and participate in their community.
- Pressure sores (also called pressure ulcers or bed sores) are wounds caused by pressure on part of the body interrupting the blood supply to the skin. People with mobility difficulties and who are over 70 are more at risk. Under the European Pressure Ulcer Advisory Panel classification system, pressure sores are graded in severity from 1 to 4.
- Grade 1 indicates the first signs of pressure damage; including redness, discolouration, swelling or heat but with intact skin. Grade 2 is usually an abrasion or blister and involves a partial thinning of the skin. Grade 3 involves full loss of skin thickness with damage to, or death of, the underlying tissue. Grade 4 indicates severe pressure damage, usually a deep wound that may go down to the bone and the death of underlying tissue.
- The Waterlow score gives an estimated risk for the development of a pressure sore in a patient. A score over 15 indicates someone is a high risk of developing pressure sores. A score over 20 indicates someone is a very high risk of developing pressure sores.
- The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.
- NICE’s Pressure ulcers: prevention and management guidelines (2015) are the national guidelines covering risk assessment, prevention and management for adults at risk of, or who have, a pressure ulcer.
- The Trust’s Guidance for the Prevention and Management of Pressure Ulceration (2019) are the local guidelines for district nurses to support patients at risk of, or who have, a pressure ulcer. These local guidelines are broadly based on the NICE guidelines above.
- Public Health England’s (PHE) Pressure ulcers: applying All Our Health (2015, updated 2018) provide additional guidance for healthcare professionals in the community.
- I have reviewed the Trust’s district nursing records.
- During the first assessment on 25 February 2020, the district nurse noted Mrs Y was a high-risk of developing pressure sores. That assessment was in line with the NICE and Trust guidance. The district nurse appropriately assessed Mrs Y’s skin, completed a body map, and repeated the assessment in a timely manner (on 3 March). However, the district nurse did not put a care plan in place for Mrs Y for over two weeks, until 13 March (after Mrs Y moved to Meadowfield House). That was fault, and not in line with the PHE or Trust guidance. I do not consider there is any injustice to Mrs Y because of the fault I have identified. The district nursing assessment on 13 March did not identify that Mrs Y’s leg wound had worsened. But still, the Trust should take action to address the potential injustice to others.
- I do not consider the district nurse provided enough detail to Mrs Y and her husband about repositioning on 25 February. The Trust’s ‘React to Red’ leaflet (which the district nurse shared with Mr Y) was robust and covered all the requirements in NICE’s guidance. However, it only referred to ‘regular’ repositioning. That was fault, and not in line with NICE guidance which suggests repositioning patients every four hours. The ‘React to Red’ leaflet should have provided more detail than ‘regular’ repositioning. I consider that fault caused Mrs Y an injustice when she returned home from Meadowfield House on 16 March. Clearly, Mr Y did not know how regularly he should have repositioned his wife. Therefore, I consider the Trust’s fault most likely worsened the moisture damage to Mrs Y’s sacrum after 16 March. That would have been painful and distressing for Mrs Y. I also do not doubt that would have caused Mr Y distress.
- I also consider the district nurse missed the opportunity to discuss a pressure relieving mattress with Mrs Y on 25 February. That was fault. Mrs Y was a high‑risk of pressure sores, so the district nurse should have discussed providing a pressure mattress. The district nursing service did not explore a pressure relieving mattress until 21 March. I accept a pressure mattress would not have fit Mrs Y’s king-size bed. However, I consider it would have been appropriate for the district nurse to have explored alternative ways to support Mrs Y at home after 25 February. That was a missed opportunity. There are no guidelines to state when someone should receive pressure relieving after an assessment. However, I consider the Trust should have most likely have put that in place when Mrs Y returned home on 16 March. On the balance of probabilities, the lack of a pressure mattress worsened the moisture damage to Mrs Y’s sacrum. That would have been painful and distressing for Mrs Y. I also do not doubt that would have caused Mr Y distress.
- I will move on to Mrs Y’s admission to Meadowfield House between 12 and 16 March.
- Meadowfield House could not provide me with its pressure area care records for Mrs Y. Therefore, I cannot comment on the quality of pressure area care staff provided to Mrs Y. That was poor record keeping. Meadowfield House either did not keep records of its pressure area care, or it cannot find those records. Either way, that was fault which will add to Mrs Y’s sense of uncertainty about the quality of Meadowfield House’s pressure area care.
- I consider the district nurse’s assessment of Mrs Y on 13 March was in line with the NICE and Trust guidance. The district nurse created a care plan for Mrs Y which would meet her needs. I am satisfied the district nurse appropriately encouraged Meadowfield House staff to reposition Mrs Y every two hours.
- When the district nurse returned on 16 March, I consider their assessment was broadly in line with the NICE and Trust guidance. However, Mrs Y had started to develop moisture damage on her sacrum. I consider the district nurse missed the opportunity to start using a barrier cream for Mrs Y. That was fault, and not in line with the NICE guidance. A barrier cream prevents skin damage for people who are a high-risk of developing moisture damage. Between 16 and 20 March, Mrs Y’s moisture damage most likely worsened without barrier cream. That would have been painful and distressing for Mrs Y. I also do not doubt Mr Y suffered distress.
- When Mr and Mrs Y self-discharged home on 16 March, there was always likely to be a harmful impact to her pressure areas. If Mrs Y told Meadowfield House she wanted to leave, Meadowfield House would most likely have planned the discharge with the Council and Trust’s district nurses. They could have jointly arranged support for Mrs Y at home. However, I consider Meadowfield House still missed the opportunity to tell the district nurses and Mr Y (as Mrs Y’s main carer) about Mrs Y’s two-hour repositioning regime. That was fault. The district nursing teams that supported Mrs Y at home and at Meadowfield House were different.
- As I have already found, the district nurses should have communicated Mrs Y’s repositioning regime to Mr Y better at the start. However, the self-discharge was an opportunity for Meadowfield House to also communicate that information to the right people. Mrs Y was a very high risk of pressure sores and needed to be repositioned safely at home without carers and a pressure mattress. Even a short delay in position changes can significantly impact vulnerable skin. When the district nurse next reviewed Mrs Y at home, they noted Mr Y was providing all her care and there was evidence of “improper” moving and handling. That would have been painful for Mrs Y, which most likely contributed to further sacrum pressure damage between 16 and 18 March. I also do not doubt Mr Y suffered distress then.
- The district nurse first identified Mrs Y’s hip sore on 21 March. I am not persuaded the hip sore developed due to any fault by the district nurses. They had reviewed Mrs Y on 18 and 20 March and, while the hip was vulnerable, the nurses did not note any concerns about the hip. I consider the hip sore most likely developed after the district nurse review on 20 March, which is possible. On 21 March, I am satisfied the district nurse planned Mrs Y’s wound care, completed body maps, completed an incident report, and frequently assessed the wound in line with the NICE and Trust guidance.
- Overall, I do not consider the Trust or Meadowfield House caused any of Mrs Y’s pressure sores. However, I am persuaded some of their actions caused the moisture damage to her sacrum to worsen. Later in this statement, I have made recommendations to remedy Mr and Mrs Y’s injustice.
- On discharge in February 2020, the Trust prescribed Mrs Y to take two tramadol twice a day for 24 days, and paracetamol when required. Tramadol is a strong painkiller to treat severe pain. Paracetamol is a painkiller for less severe pain.
- In response to Mr Y’s complaint, the Council said Mrs Y refused paracetamol and took the tramadol as prescribed.
- Mr Y says Meadowfield House told him he would have to provide paracetamol for his wife. He got 100 tablets from his GP and gave them to Meadowfield House. However, Meadowfield House has denied ever receiving them.
- I have reviewed Meadowfield House’s records from the time, and I cannot find any evidence Meadowfield House asked Mr Y to provide the paracetamol. I do not doubt Mr Y’s version of events. However, without independent witnesses, I cannot say, even on the balance of probabilities, what was agreed during Mr Y’s conversation with Meadowfield House staff. Meadowfield House has provided evidence it had its own supply of paracetamol.
- Mr Y says Meadowfield House did not always provide pain relief to his wife.
- The Medication Administration Record (MAR) sheet lists a patient’s medication, the quantity of tablets received, the dose, frequency and time of administration over a four-week period. Home staff sign it, acknowledge receipt of medication, record when they administer medication or if, for any reason, it is not given.
- I have considered Meadowfield House’s MAR charts. They show that when staff offered Mrs Y paracetamol, she refused it. The MAR charts also showed Mrs Y took two tramadol twice a day between 11 and 16 March. That was in line with the Trust’s prescription. I consider Meadowfield appropriately managed Mrs Y’s pain and did not act with fault.
- Within four weeks of this decision, the Trust should:
- Apologise to Mrs Y for the pain she suffered between 16 and 20 March 2020 by not applying barrier cream.
- Apologise to Mrs Y for contributing to her worsening sacrum pressure sore after 16 March by not considering a pressure relieving mattress. Also, by not explaining to Mr Y that before 12 March he should be repositioning his wife at least every four hours.
- Apologise to Mr Y for the distress he suffered at witnessing his wife in pain.
- Pay Mrs Y and Mr Y £600 and £100 respectively in recognition of their injustice.
- Relevant staff are aware they need to complete care plans with patients, and discuss and consider pressure relieving equipment, as soon as they are identified as a high-risk of pressure sores.
- It reviews its communication of repositioning, so it is in line with the NICE guidance on repositioning patients.
- Apologise to Mrs Y for the uncertainty caused by Meadowfield House’s poor record keeping.
- Apologise to Mrs Y for Meadowfield House contributing to her worsening sacrum pressure sore after 16 March.
- Apologise to Mr Y for the distress he suffered at witnessing his wife in pain.
- Pay Mrs and Mr Y £450 and £100 respectively in recognition of that injustice.
- Staff are aware they should be robustly recording service user’s care and treatment, such as for pressure area care. Also, ensure staff are appropriately storing and archiving service user’s care records.
- Reviews its policies so when someone discharges themselves, it has a process to contact relevant professionals to avoid the service user going without support.
- I consider the Trust and Meadowfield House jointly contributed to Mrs Y’s moisture damage to her sacrum. That caused her pain and distress, and Mr Y also suffered distress at witnessing his wife’s pain.
- I also consider Meadowfield House appropriately administered pain relief to Mrs Y.
Parts of the complaint that I did not investigate
- The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe it is unlikely they could add to any previous investigation by the bodies. (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended).
- The Council has already apologised for the problems Mr and Mrs Y had with meals, her room, and the language barrier with staff. I do not consider an investigation into those issues would add anything to the previous investigation by the Council.
Investigator's decision on behalf of the Ombudsman