A care home resident in Fife died after NHS nursing staff failed to properly check for signs of infection, a watchdog has ruled.
The resident, referred to as A, had been suffering from sores on their legs but was taken to hospital after developing a significant infection.
After the patient’s death, the family complained about the treatment supplied by district nurses in the home – which has not been identified.
They said the NHS nurses had failed to identify the deterioration in their legs and had not alerted a GP, nor made a referral to a specialist practitioner.
They said the dressings would often become saturated in fluid, requiring care home staff to apply further dressings.
Wound assessments ‘incomplete’
The Scottish Public Services Ombudsman (SPSO) launched an investigation and after seeking independent advice, officials found “a number of failings” in how the resident’s sores were treated.
A report said: “Wound assessments carried out were incomplete and not carried out at the required frequency and… the wound dressings used were inappropriate, often contradicting the findings of examinations, and contrary to current guidelines.
“We noted that district nursing staff had failed to carry out baseline observations and tests to check for the presence of infection or sepsis (blood infection) despite noting that A was as ‘flat’ and ‘lethargic’.”
NHS Fife has been asked to apologise to the family for “failing to provide reasonable care and treatment”.
The SPSO decision also said: “We found that the district nursing staff’s record-keeping was poor and not in accordance with relevant professional standards given there was no documented record of interactions with A on certain dates.”
Board claimed care was ‘appropriate’
The watchdog also had concerns around the board’s complaint-handling, monitoring and governance system.
This was because, after the family complained, the board carried out its own investigation and ruled “consistent and appropriate care” had been provided.
It said the health authority should ensure that failings and good practice are identified and that learning from complaints is used to drive service development and improvement.
The board should also comply with its own complaint-handling guidance when investigating and responding to complaints, it added.
NHS Fife has been contacted for comment.
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