Summary: We will not investigate Mr C’s complaint that a specialist chair caused his wife, Mrs C, pressure sores. This is because an investigation would most likely not conclude the specialist chair solely caused the pressure sores.

The complaint

1. Mr C complains on behalf of his wife, Mrs C, about South Gloucestershire Council (the Council) and Sirona Care and Health CIC’s (Sirona) joint decision to provide her with a Back Leg Tilt (BLT) chair which he says caused her grade four pressure sores. Those pressure sores have not fully healed. The events have also caused Mrs C depression. Mr C wants the Council and Sirona to add an addendum to their records to reflect the mistake he says they have made. He also wants them to apologise and pay financial redress to remedy the physical pain and mental distress Mrs C suffered.

Back to top

The Ombudsmen’s role and powers

2. 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 further investigation would not lead to a different outcome or they cannot achieve the outcome someone wants. (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)
3. If there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 

Back to top

How I considered this complaint

4. I have considered information Mr and Mrs C have provided in writing and over the phone.
5. Mr and Mrs C had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Back to top

What I found

Key facts

6. In July 2019, the Council and Sirona agreed funding for the BLT chair. The Council delivered that chair a month later, and Mrs C reported she was very happy with it.
7. In September 2019, Mrs C and her carers reported difficulties positioning Mrs C in the BLT chair. The OT subsequently provided instructions to Mr C (to then share with carers) to better support his wife.
8. In February 2020, a district nurse (for Sirona) raised a safeguarding concern to the Council. They said Mrs C had developed a grade three pressure sore, which may have been caused by neglect by Mr C. Mr C refuted that he neglected his wife. Rather, he said Mrs C did not want him to escalate concerns about her pressure sore when it first appeared.
9. In May 2020, district nurses raised a second safeguarding concern to the Council. The pressure sore had increased to grade four. They said Mr C was manually handling his wife (which she was happy with) rather than using equipment to transfer his wife. The Council arranged for the Occupational Therapist (OT) to review Mrs C. During that review, in late May 2020, Mrs C asked the OT to remove the BLT chair, as its material caused friction which caused the pressure sores.
10. In early June 2020, the OT carried out a manual handling risk assessment. Mrs C had no concerns with her husband lifting her up. But the OT recommended Mr C use the equipment to transfer his wife. The OT said Mr C manual handling his wife could cause further skin damage.

Analysis

11. 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.
12. 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 involve the death of underlying tissue.
13. There have been different explanations for Mrs C’s pressure sores:
• Mr and Mrs C say the BLT chair caused the pressure sores because the chair’s material caused friction which sheared her skin.
• The OT felt the Council and Sirona should have provided a different chair to the BLT in September 2019.
• Sirona staff were concerned about Mr C’s manual handling.
14. It is possible Mrs C developed pressure sores due to a combination of the reasons above. Therefore, I do not consider, on the balance of probabilities, an investigation would conclude the BLT chair solely caused the pressure sores.
15. The gap between Mrs C reporting a problem with the BLT chair, and then developing the pressure sores was six months. There are too many unknowns in that period about the support Mrs C received from Mr C and private carers at home to be able to conclude that the chair was the sole cause of the pressure sores.
16. Also, Mr and Mrs C have not complained about the district nursing support after February 2020. I cannot investigate the actions of the district nurses, which could have potentially contributed to the second pressure sore.

Back to top

Final decision

17. I do not consider an investigation would conclude the BLT chair solely caused Mrs C’s pressure sores.

Investigator’s decision on behalf of the Ombudsmen

Back to top

Investigator's decision on behalf of the Ombudsman