NHS rebuked for bed sores death

Mrs A was taken to the ERI in 2012. Picture: Toby williams
Mrs A was taken to the ERI in 2012. Picture: Toby williams
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HEALTH chiefs have been criticised after an elderly woman who was admitted to hospital following a fall at home died after bed sores were not properly treated.

An ombudsman’s investigation upheld a complaint against NHS Lothian about its failure to prevent the woman developing pressure ulcers or to deal with them adequately.

The finding comes after NHS Lothian missed its target of eradicating bed sores from hospital wards by March this year.

The ombudsman said the woman, identified only as Mrs A, was admitted to Edinburgh Royal Infirmary on September 28, 2012 after a fall at home. A scan found a small fracture in her left hip.

Two assessments of her skin condition produced different risk levels for pressure ulcers and no preventative action was taken.

She was transferred to Liberton Hospital for rehabilitation on October 5, but the ombudsman said no handover notes were provided on what treatment she was receiving or highlighting any concerns.

The report said Mrs A went on to develop bed sores on her heels and at the base of her spine. “One of these became very severe, and eventually became infected,” it said.

She was transferred on December 10 to Corstorphine Hospital and discharged to a nursing home 12 days later.

The ombudsman said Mrs A had to wait 28 days for a specialist nurse to review her pressure ulcers – “an excessive delay”.

He said the infection spread to Mrs A’s bone and ultimately led to her death, six weeks after she was discharged.

He recommended NHS Lothian should review prevention and care of pressure ulcers at Liberton and develop an action plan for improvements.

Sarah Ballard Smith, nurse director at NHS Lothian, said: “We have apologised to the family of Mrs A, but I would like to repeat that apology publicly and express our sincere condolences once again.

“We accept the ombudsman’s recommendations and have already put them into practice by reviewing practices and procedures in relation to the risk, care and treatment of pressure ulcers and implementing new practices.

“We have also appointed a dedicated tissue viability nurse within the hospital to ensure that significant differences are made to care.”