Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Hywel Dda University Health Board
Mrs A complained about the care that Hywel Dda University Health Board (“the Health Board”) afforded her husband.
The investigation found there had been no delay in the debriding (the removal of dead/infected skin) of Mr A’s sacrum (lower back) wound (“the wound”). The decision to leave the wound left open with a Vacuum Assisted Closure1 dressing applied (as opposed to a skin graft2 procedure being undertaken) was clinically appropriate. There were no additional actions that could have been taken to prevent the wound being contaminated from soiling. Accordingly, these aspects of Mrs A’s complaint were not upheld.
The quality of the clinical records hindered the Ombudsman’s ability to determine whether the VAC procedure and irrigation tube treatments3 were undertaken consistently and as per the treatment plan. Whilst the investigation did not find that treatment was suboptimal, it did find that the failure to accurately record all aspects of Mr A’s treatment and care amounted to an injustice and accordingly this aspect of Mrs A’s complaint was upheld.
The Ombudsman was satisfied that the wound management and treatment plans formulated by the Tissue Viability Service were clinically appropriate; involvement was timely and regular reviews were undertaken. Whilst there was a lack of holistic assessment at the outset this did not appear to have impacted on management and treatment moving forward. However there was a failure to accurately record all aspects of Mr A’s treatment plan and so there remained a level of uncertainty and concern around this issues; therefore this aspect of Mrs A’s complaint was upheld.
The investigation found that Mr A’s feeding and nutritional needs were not met from his admission (June 2019) to September 2020. Mr A was scored incorrectly in the referral to dietetics and there was a delay in assessment. The investigation found that on balance the lack of adequate nutrition impacted upon the wound healing process. However, it was not possible to determine with any real certainty how substantial this impact was given the range of other contributing factors. The delay in provision of adequate nutrition and the knock-on effect on wound healing represented a significant injustice to Mr A and accordingly this aspect of Mrs A’s complaint was upheld. In addition, for the reasons already outlined, the investigation also upheld Mrs A’s complaint that between admission and September 2020 Mr A’s nutritional/feeding care was not appropriately co-ordinated.
The investigation found that Mr and Mrs A were given regular and detailed updates on Mr A’s condition and management plan. It was regretful that despite meetings being held and updates being provided, Mrs A was not satisfied with the effectiveness of communication however the Ombudsman considered that appropriate attempts were actioned in order to try and relay and convey Mr A’s complex management and treatment plan. This aspect of Mrs A’s complaint was not upheld.
The investigation found that a referral could have been made to the Plastics Team (based in a neighbouring Health Board) at an earlier juncture. Logistically, there would have been difficulties in the Plastics Team taking over inpatient care. Overall, the investigation found that Mr A’s wound management care was appropriately co-ordinated and so this aspect of Mrs A’s complaint was not upheld.
The investigation found that the frequency and timings of the Magnetic Resonance Imaging scan (“MRI” – The use of strong magnetic fields and radio waves to produce detailed images of the inside of the body) undertaken were clinically appropriate and so this aspect of Mrs A’s complaint was not upheld.
Mrs A complained that Mr A’s fungal nail infection was not managed appropriately. Following consideration of the clinical records from June to September 2019 there is no reference to Mr A having a fungal nail infection and so this aspect of Mrs A’s complaint was not upheld.
The Health Board agreed to action the following:
• Provide a fulsome apology to Mrs A for the failures identified.
• Provide a circular to the Tissue Viability Service on the importance of undertaking (and recording within the clinical records) an overarching assessment of the patient’s holistic needs.
• Develop a TNP care plan/template for clinical staff to complete so that there is evidence to demonstrate that a consistent approach has been given to the therapy from all disciplines.
• As part of the Standard Operating Procedure, prepare a plan to provide nursing staff with training on the correct nursing documentation standards in respect of evidencing detailed dressing treatment plans.