By Grant Smith

THE CARE given to a paraplegic amputee suffering from pressure sores in Ninewells Hospital, Dundee, was “completely unacceptable” and caused him additional suffering, an inquiry has found.

The Scottish public services ombudsman said the hospital had “failed” in delivering significant aspects of the patient’s care and has ordered a series of improvements to treatment planning, record-keeping and staff training.

The patient’s son made three formal complaints, alleging inadequate treatment, inadequate monitoring, and an inappropriate decision to continue with a course of treatment. All three have been upheld.

It was in summer 2006 that the man, paraplegic as a result of a previous spinal condition, was admitted to Ward 11 at Ninewells. Due to reduced blood supply to his right arm, it had to be amputated below the elbow.

The ombudsman’s report explained that the patient, known only as Mr A, had three sores on his buttocks and hip.

During his time in Ward 11 he used a bed with a pressure-relieving mattress, which was on trial at the hospital.

However, staff did not tell their colleagues in Ward 19 that he needed such equipment when he was transferred there.

Mr A was in hospital for two months before being discharged, only to be swiftly readmitted for plastic surgery to deal with pressure ulcers.

The ombudsman’s medical adviser said the decision not to transfer the special bed with Mr A was “flawed” and the lack of information between the wards contributed to a standard of care that was “not acceptable.”

The report added, “There is no evidence to suggest that an assessment of Mr A’s pressure sores was undertaken.”

The report continued, “Much of the nursing documentation was incomplete. Examples include a pressure area treatment plan review which was blank.”

Mr A spent some of his time sitting up in his electric wheelchair.

However, there was no formal assessment of his ability to move and independently relieve pressure on the area of the sores after his arm amputation, which had left him with only one fully-functioning limb.

Staff should also have sought specialist advice on the management of the sores and future care planning, but did not do so.

The ombudsman said, “Although action was taken to monitor Mr A, I am of the opinion that seeking further advice—given his medical history—would have been appropriate in this case, as would a more detailed care plan.”

NHS Tayside was asked about the medical treatment given to Mr A. It replied that a multi-disciplinary team had decided not to refer him to a plastic surgeon because there was evidence his wound was healing, with a reduction in the amount of dead tissue.

However, the medical adviser could find no written evidence of this and the ombudsman said, “The lack of documentation regarding this decision is unsatisfactory. The importance of documenting facts cannot be over-emphasised.”

The conclusion was that there had been “some serious shortcomings in the standard of care delivered to Mr A during his period of hospitalisation,” for which NHS Tayside has been told to apologise.

NHS Tayside has agreed to accept a series of recommendations made by the ombudsman and report back when they have been carried out.

These include providing evidence that Ninewells has in place a robust standard for record-keeping and that there is a formal programme of education and training for Ward 11 staff on the transfer of patients.

Managers have also promised to create a quality assurance system for all patients suffering from pressure sores to ensure their care plans are sufficiently detailed and that they are properly monitored.