Mr W complained that the Health Board failed to provide appropriate wound care to his father, Mr R, during his admission to a Community Hospital. Mr R had undergone a total hip replacement following a fall at home and was subsequently discharged to the Community Hospital for rehabilitation. Mr W said that staff at the Community Hospital failed to identify, manage and treat his father’s post-operative infection, or arrange for his transfer back to the District General Hospital, for treatment, appropriately. He said that, as a result of the failings in care, Mr R succumbed to further post-operative complications, developed hospital-acquired pneumonia, and sadly passed away.

The Ombudsman found that appropriate dressings were not used at any time throughout Mr R’s care and his wound clips remained in situ throughout his admission, which was likely to have exacerbated his infection. In addition, there was no comprehensive review of Mr R or his wound by a doctor after the initial admission assessment, despite clear evidence that infection was present. Senior medical advice should have been sought promptly from the District General Hospital and the failure to do so delayed appropriate treatment for Mr R by at least a week, which made it more difficult to treat the infection, and for Mr R to fight it. The Ombudsman also found that the Health Board failed to ensure that it had fully informed the Welsh Ambulance Services Trust of Mr R’s condition, or that appropriate transport was arranged to transfer him back to the District General Hospital.

It was recommended that the Health Board apologise to Mr W, and offer him £2000 in recognition of the failures identified and the repercussions for Mr R. It was also recommended that the Health Board would share the outcome of this complaint with staff at both the Community Hospital and the District General Hospital, highlighting the important learning points including early recognition of signs in the deteriorating patient, comprehensive record-keeping and the sharing of appropriately detailed hand-over information.

It was also recommended that the Health Board ensure its Wound Management Guidelines are up to date and remind all staff of the properties/appropriate uses of the listed dressings, as well as undertake an audit to determine that all staff training on the Principles of Wound Management is up to date. Where training is not up to date, it was recommended that those staff members should be given training as soon as possible. Finally, it was recommended that the Health Board should provide evidence to the Ombudsman that it has robust handover systems in place at both the District General Hospital and the Community Hospital for arranging patient transfers and that it has adequate arrangements in place for senior medical review at the Community Hospital.