Hounslow and Richmond Community Healthcare NHS Trust

7. Miss E is complaining about aspects of the care and treatment provided to her late father, Mr E, by Hounslow and Richmond Community Healthcare NHS Trust (the Trust) between July and September 2020. Specifically, she complains that the Trust did not do enough to prevent her father developing a pressure sore, and then did not do enough to control and treat the pressure sore.

8. Miss E says that her father experienced extreme pain at the end of his life due to the pressure sore and this was very distressing for her and her family to witness. She said that they could not spend quality time with their father at the end of his life because he was on a high dose of morphine to try and control the pain. She said that the morphine shortened his life, and he may have lived longer if he had not developed the pressure sore. She said this has made it difficult for them to come to terms with his death.

9. As an outcome to her complaint Miss E would like an apology, service improvement, and a financial remedy.

10. Mr E’s GP referred him to the Trust on 9 July 2020.

11. On 10 July a community matron first visited Mr E and conducted a Waterlow assessment. The Waterlow score is a tool used by hospitals and nursing homes to assess the likelihood that a patient may develop pressure sores.

12. By 16 August Mr E was struggling to pass urine so a catheter was fitted. Miss E said he was bed bound by that date.

13. On 18 August the community matron undertook a sacral (base of the spine) check and documented that the area was red, and she dressed it for protection. She also made the decision to order a hospital bed and a pressure relieving mattress.

14. On 19 August the bed and mattress were delivered. Overnight Mr E developed a small category 2 pressure sore. A category 2 pressure sore is an open wound or blister, a category 3 is a deep wound that reaches the deeper layers of the skin, and a category 4 is a very deep wound that may reach the muscle and bone. The nurses reported Mr E’s pressure sore and documented it.

15. On 20 August the matron checked the area and documented that it was improving.

16. On 21 August the matrons documented that Mr E was attempting to walk to the bathroom forgetting he had a catheter. He was complaining of lower back pain, so a syringe driver was started (a small, battery-powered pump that delivers medication at a constant rate throughout the day and night).

17. On 23 August Mr E was complaining of back pain. The skin was red but intact and the nurses applied a dressing for protection.

18. On 25 August the matron noted that the sacrum was red, blanching, and the skin was very vulnerable.

19. On 26 August the matron felt that Mr E would benefit from a different mattress (Centrius Lux) and ordered one.

20. On 27 August the Centrius Lux mattress was delivered, and he was transferred onto this. The matron noted that his sacrum was vulnerable and red and took a photograph.

21. On 29 August the matron checked the pressure areas and Mr E had progressed to a category 3 sore.

22. On 2 September Mr E sadly passed away.

The prevention of the pressure sore

26. Miss E complains that the Trust did not do enough to prevent her father developing a pressure sore. She said it was first documented that he had developed this on 19 August, but he was complaining of a sore back for at least a few days before this.

27. She said that he had been deteriorating since July, but he had a catheter fitted on 16 August and he was bed-bound by that date, as the carers had told him not to get out of bed as he was at high risk of falling.

28. The NICE guidance states that to prevent pressure sores the community nurses should: ‘Carry out and document an assessment of pressure ulcer risk for adults receiving NHS care in other settings (such as primary and community care and emergency departments) if they have a risk factor, for example: • significantly limited mobility (for example, people with a spinal cord injury) • significant loss of sensation • a previous or current pressure ulcer • nutritional deficiency • the inability to reposition themselves • significant cognitive impairment.

Consider using a validated scale to support clinical judgement (for example, the Braden scale, the Waterlow score or the Norton risk-assessment scale) when assessing pressure ulcer risk’.

29. The clinical records show that the nurses conducted a Waterlow assessment on 14 July. The Waterlow tool identifies three 'at risk' categories: 1. a score of 10-14 indicates 'at risk' 2. a score of 15-19 indicates 'high risk', and 3. a score of 20 and above indicates very high risk.

30. Mr E’s Waterlow score was 14, his mobility was restricted, but at this point he was not bedbound. He was still mobilising to the bathroom.

31. On 6 August the nurses repeated Mr E’s Waterlow assessment, and he scored 24, indicating a ‘very high risk’ of pressure sores. These assessments were in line with the NICE guidance.

32. The NICE guidance states if a patient is considered at risk of developing a pressure sore, a pressure ulcer prevention plan should be put in place. The NICE guidance says this should include: • ‘offering adults who have been assessed as being at high risk of developing a pressure ulcer a skin assessment • Encouraging adults who have been assessed as being at high risk of developing a pressure ulcer to change their position frequently and at least every 4 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required.

• Use a high-specification foam mattress for adults who are assessed as being at high risk of developing a pressure ulcer in primary and community care settings’.

33. Despite being ‘at risk’ from 14 July and ‘very high risk’ from 6 August, we have seen no evidence that a pressure sore prevention plan was put in place until 19 August 2020 when Mr E developed a category 2 pressure sore on his sacrum.

34. We have seen no evidence that the nurses offered a skin assessment or advised on positional changes until 18 August. We have seen no evidence that the nurses discussed a hospital bed with a pressure mattress until 11 August. This is not in line with the NICE guidance and is an indication of a failing.

35. The National Pressure Ulcer Advisory Panel guide states that ‘most, but not all, pressure ulcers are avoidable’. The National Patient Safety Agency explains that this means that a pressure sore will only be classed as unavoidable if the person receiving care develops a pressure ulcer despite appropriate assessments, care planning with interventions, and monitoring of the interventions.

36. As the Trust did not provide a pressure sore prevention care plan to Mr E until he had already developed a pressure sore, it is possible he sustained an avoidable pressure sore due to the lack of care planning from 17 July.

37. Miss E says that her father experienced extreme pain at the end of his life due to the pressure sore and this was very distressing for her and her family to witness. She said that they could not spend quality time with their father at the end of his life because he was on a high dose of morphine to try and control the pain. She said that the morphine shortened his life, and he may have lived longer if he had not developed the pressure sore.

38. The notes show that Mr E was complaining about a significant amount of back pain at the end of his life. However, this pain was not his from his sacrum, which is the ‘tailbone’ and if painful would be to the top of the buttock cleft. The records suggest his pain was not solely caused by the pressure sore.

39. We appreciate that the pressure sore would have caused Mr E some pain and discomfort. We also appreciate that it was extremely distressing for Miss E to discover that her father had developed a pressure sore.

40. We have discussed this with the Trust. Having considered the evidence again it said it wants to apologise to Miss E for the mistakes in the pressure sore care planning.

41. It also told us it will consider how this happened and if there are any service improvements it should make, to prevent this happening again.

42. The Trust’s acknowledgement of failings and consideration of service improvements are in line with the types of remedy set out in our principles for remedy. We are satisfied this resolves this element of Miss E’s complaint.

Treatment of pressure sore

43. Miss E also complains that the Trust did not do enough to control and treat the pressure sore after this developed. She said this changed to a category 3 sore. She said that the Trust only changed his mattress to the Centrius Lux on 27 August and she feels that this should have been done earlier.

44. The NICE guidance on pressure sores says nurses should ‘categorise each pressure ulcer in adults using a validated classification tool. Use this to guide ongoing preventative strategies and management. Repeat and document each time the ulcer is assessed’.

45. On 19 August Mr E developed a pressure sore. In line with the NICE guidance, the nurses examined this, categorised this as category 2, and documented this in the records. The nurses completed an incident report, cleaned and dressed the wound, and advised on positional changes at this stage. Unfortunately, the pressure sore developed into a category 3 despite proper care planning and interventions.

46. The records also show that Mr E was not keen on having a hospital bed at home when this was initially discussed with him on 11 August. On 18 August he did consent to a hospital bed, and a bed and mattress were delivered the following day. This was a Dualflex mattress. Miss E feels that her father should have had the Centrius Lux mattress at this stage.

47. Our nursing adviser said the Dualflex is a hybrid mattress as it combines static foam with alternating air, which is often more comfortable for patients than a standard alternating air mattress. The Dualflex is used for patients at high risk of pressure sores and those with pressure sores.

48. The Centrius Lux is an alternating air mattress used for patients with existing pressure sores and those at high risk of pressure sores and it was also appropriate for Mr E.

49. Both mattresses were appropriate for Mr E, however our nursing adviser said at the end-of-life comfort is often prioritised, which is why the Trust chose the Dualflex mattress in the first instance.

50. We have not seen any indications of failings in this part of the complaint so we will not be taking any further action. We hope our explanation clearly explains our reasons and provides reassurance to Miss E that the nurses acted in line with the relevant guidance following the discovery of the pressure sore.

Conclusion

51. We appreciate how upsetting this period was for Miss E as she was her father’s main carer and she had to witness him deteriorating. It is understandable why the development of the pressure sore was extremely distressing for Miss E, as she now questions whether this could have been prevented.

52. We hope the steps we have taken to resolve her concerns, alongside our explanations, offer reassurance that her concerns have been looked at in detail and followed up with the Trust, and that her complaint has resulted in changes being made to improve the service provided.

1. We have carefully considered Miss E’s complaint about Hounslow and Richmond Community Healthcare NHS Trust (the Trust). We thank Miss E for taking the time to discuss her concerns with us. We appreciate it is never easy to talk about events surrounding the death of a parent.

2. We have seen some indications of failings in the Trust’s care planning to prevent a pressure sore.

3. We discussed these points with the Trust. The Trust has looked again at the evidence and agreed to write to Miss E to acknowledge her outstanding concerns and apologise. It has also agreed to look at any service improvements it can make to prevent these events happening to another person.

4. The Trust’s actions are in line with our guidance on remedy. As we have agreed an appropriate resolution to these parts of the complaint, we will not be looking at them any further.

5. We have seen no indication of failings in the Trust’s treatment of the pressure sore after it developed.

6. We will not be looking at this part of the complaint any further. We recognise this may be disappointing. We hope this reassures Miss E that the Trust acted in line with the guidance to ensure that it appropriately treated the pressure sore after it developed.