Clinical treatment outside hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Powys Teaching Health Board
Ms B complained about the care and treatment her partner, Mr C, received for his wound from Powys Teaching Health Board’s (“the Health Board”) District Nursing Team between 21 September and 4 November2019.
The Ombudsman’s investigation found that on Mr C’s initial discharge from hospital, the District Nursing Team undertook an appropriate assessment and carried out the wound care regime appropriately. The District Nursing Team changed the regime to a different regime which was appropriate and evidence based. The Ombudsman found that between 1 and 4 November Mr C was not seen by the District Nursing Team, however, given the condition of Mr C and the concerns about his wound, he should have been seen on a daily basis. The Ombudsman’s investigation also found that there were record keeping failings by the District Nursing Team. He found that the lack of clearly documented care plan, and reliance on Ms B to update individual nurses, may have led to inconsistency in Mr C’s wound management. These omissions in clinical record keeping and care caused uncertainty for Ms B and Mr C which was an injustice. Accordingly, the Ombudsman upheld this element of Ms B’s complaint. The Ombudsman’s investigation found that the Health Board’s complaint response was delayed and missed an opportunity to learn lessons from Mr C’s care, which was an injustice. Accordingly, the Ombudsman upheld this element of Ms B’s complaint.
The Health Board agreed to apologise to Ms B and Mr C, and offer a payment of £500 in respect of the injustices identified. It also agreed to share the report with the Concerns Team and District Nursing Team for reflection. The Health Board agreed to carry out its planned review into its complaint response templates and report its findings back to the Ombudsman. Finally, the Health Board agreed to undertake a review to consider whether it should develop a protocol for the management of chronic infected wounds in community settings.