Surrey and Sussex Healthcare NHS Trust

3. Mrs A complains that after being admitted to hospital 1 May 2024, staff failed to adequately care for her husband, Mr A’s, pressure ulcers during his stay, and as a result these become incredibly severe. She says staff failed to accurately category his pressure ulcers and give appropriate treatment. She says this was incredibly physically distressing for her husband, and she and her daughters still have nightmares about his treatment.

4. She also complains that Mr A did not receive physiotherapy when he should have when he arrived in hospital, due to the Bank Holiday. Mrs A says that she is concerned that the delay in Mr A receiving physiotherapy impacted his mobility and as a result his pressure ulcers deteriorated more severely and rapidly than they should have.

5. She also complains that a doctor failed to empathetically tell Mr A and his family of his 12-week prognosis, as they told them in a public and filled ward. She says this was very upsetting for her family.

6. She also complains that in its complaint response, the Trust incorrectly said Mr A did not want to move or be moved which would have helped his pressure ulcers. She says the complaint response was upsetting and frustrating.

7. She is seeking an apology and explanation for what went wrong, service improvements and financial remedy.

8. Mr A was receiving palliative care for terminal cancer. On 1 May 2024, Mr A had a fall at his home and was admitted to hospital.

9. He had pressure ulcers, which were assessed at category two. Pressure ulcers are categorised from one to four on depth and severity. The higher the category, the more severe the pressure ulcer is. Category two pressure ulcers mean that some of the outer surface of the skin or deeper layer of the skin is damaged, which can look like an open or burst blister and lead to skin loss.

10. Mr A was in hospital for one month. During his stay, his pressure ulcers deteriorated from category two to three. This meant that the tissue under Mr A’s pressure ulcers was damaged and there were signs of dead tissue.

11. On 10 May, Mr A and his family were told that Mr A had a prognosis of less than twelve weeks to live.

12. During his admission, the Trust issued a Duty of Candour letter to Mr A, informing him his sacral skin wound (type of pressure ulcer) had deteriorated during his stay in hospital.

Treatment of Mr A’s pressure ulcers

16. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and although we acknowledge that Mr A’s pressure sores did sadly get worse, we do not believe it was because anything went wrong.

17. Mrs A told us that staff failed to adequately care for Mr A’s pressure ulcers during his stay, and as a result his pressure ulcers become incredibly severe. She says this was incredibly traumatic for Mr A, her and their daughters.

18. The Trust explained that staff performed a skin assessment when Mr A was admitted to hospital, which identified category two pressure ulcers, which are typically managed by ward nurses. The Trust said that despite staffs’ best efforts to encourage regular repositioning, appropriate dressings, medication, a nutritious diet and daily skin checks, Mr A chose to decline repositioning on several occasions, and therefore his pressure ulcers deteriorated to category three. It said it understood how difficult and uncomfortable these interventions can feel and respected his decision. It said staff arranged for an expert wound review which ensured appropriate treatment.

19. Our clinical adviser told us that staff acted in line with NICE Pressure Ulcer Standards throughout Mr A’s stay in hospital. They said that upon Mr A’s admission to hospital, staff did a risk assessment of Mr A’s pressure ulcers to determine what measures they should take to prevent his existing ulcers from deteriorating and prevent him from developing new ulcers. They said that staff correctly assessed Mr A as high-risk, due to his existing pressure ulcers, and took interventions in line with their high-risk assessment throughout Mr A’s hospital stay.

20. NICE Standards outline that staff should ensure that patients who are assessed at high-risk receive: frequent skin assessment, frequent repositioning at least every four hours including offering to help patients unable to move themselves and using appropriate equipment if needed, a high-specification mattress, dressing changes and barrier creams. Our adviser confirmed that staff attempted to take all these actions.

21. Crucially, our adviser noted that while staff attempted to adopt all the high-risk interventions, Mr A repeatedly declined skin assessments and repositioning throughout his hospital stay. They said that it was Mr A’s right to deny interventions because he had full capacity and staff acted in line with the Nursing Code to respect, support and document a person’s right to accept or deny care and treatment.

22. We understand that Mrs A disagrees that Mr A did not want to move and told us that she would find it helpful to see which dates Mr A denied treatment during his stay. Mr A’s medical notes say that Mr A denied repositioning on 2, 3, 10, 13, 14, 15, 17, 18, 20, 21, 22, 23, 24, 26, 27, 28, 29 May, and that he denied a skin assessment on 14, 15, 17, 18, 22, 23 May. On some of these days, Mr A denied these interventions multiple times. Records say that Mr A was reluctant to be turned due to discomfort and was informed about the risk of his pressure ulcers getting worse if he continued to deny repositioning. Records show that on a few of the occasions that Mr A denied, Mrs A was also present. However, as she was not present all of the time, it may simply be that she did not realise how often this happened. It is important to note that we are not blaming or judging Mr A for not wanting to be repositioned. That was his right, and we know he was already in a lot of pain and discomfort. It may be that he just wanted to minimise that by not moving any more than he felt he needed to.

23. A tissue viability nurse (TVN – a registered nurse with specialist qualifications in wound prevention and management) wrote in the records that they advised Mr A to accept interventions and that his lack of turning was the main contributing factor for his pressure ulcers deteriorating to category three. They wrote that Mr A said he wanted to stay in the position he was in because it was more comfortable.

24. Records document that a nurse had a conversation with Mrs A following the Trust’s Duty of Candour letter, as Mrs A was not happy that the letter said that the deterioration of the pressure ulcers was due to Mr A declining interventions. The nurse’s notes say that they explained to Mrs A that Mr A always declined to be touched despite pain relief medication, and that Mr A had capacity to decline. Records document that Mr A felt that the level of medication he was taking was sufficient and denied higher doses of morphine because of its difficult side effects such as nausea and sleepiness.

25. We understand it might be confusing and distressing to Mrs A for Mr A’s medical records to reflect a different account to what she remembers. We hope that this reassures her that staff acted in line with NICE guidelines and tried their best to prevent Mr A’s pressure ulcers from deteriorating. Again, we are in no way judging or blaming him for any of his decisions. It was his right to decide what he wanted and what he felt was more likely to be most comfortable for him.

26. NICE Standards outline that there are many prevention and management options available to manage high-risk pressure ulcers. Our adviser told us that some of these were not appropriate for Mr A, such as nutritional supplements and hydration as Mr A was eating well and no interventions were necessary. They said that options such as negative pressure wound therapy (controlled suction to pull wound fluid and promote blood flow), electrotherapy (electrical stimulation to encourage tissue repair) or hyperbaric oxygen therapy (100% pure oxygen in pressurised chamber to supply oxygen to the wound) were unfortunately not appropriate for Mr A due to his terminal illness and short prognosis.

27. Our adviser told us that Mr A saw a TVN in the appropriate timeframe. They said that pressure ulcers category two and below are managed by ward nurses. They said that when staff saw there had been a deterioration, they contacted a TVN who then assessed the pressure ulcers as category three. They said that staff acted in line with the Nursing Code to accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care, and make a timely referral to another practitioner when any action, care or treatment is required.

28. Mrs A believes that staff incorrectly graded Mr A’s pressure ulcers as category three when they should have been graded category four.

29. Our adviser told us that it can be very difficult to determine whether a pressure ulcer is category three or four. They said that from Mr A’s medical records and the photos Mrs A provided, Mr A’s pressure ulcers seem to be on the cusp of category three and four. They said that in order for staff to assess Mr A’s pressure ulcers as category four, staff would have needed to debride the pressure ulcers to understand the depth of the ulcers. They said that debridement involves removing the dead, damaged or infected tissue from the ulcers and can be a surgical procedure. They said it would not have been appropriate for Mr A to experience debridement due to him being terminally ill and having a short prognosis. They said as a result of correctly choosing not to debride Mr A’s pressure ulcers, staff were unable to assess the ulcers’ depth and assess them as a category four. They said that if Mr A’s pressure ulcers had been assessed as level four, then the difference in interventions would have been marginal, such as receiving antibiotics.

30. We hope that this reassures Mrs A that Mr A received the care he should have done during his hospital stay. We do not underestimate how difficult Mr A’s hospital stay must have been for him, and that the deterioration of his pressure ulcers was incredibly shocking and distressing for Mrs A and their daughters. We have seen no indications that staff got anything wrong in how they cared for Mr A’s pressure ulcers.

Access to physiotherapy

31. Mrs A complained that Mr A did not receive physiotherapy when he should have when he arrived in hospital due to the Bank Holiday. Mrs A told us she was concerned that the delay in Mr A receiving physiotherapy impacted his mobility and as a result his pressure ulcers deteriorated.

32. The Trust said that it could not provide Mr A physiotherapy services as its classified as non-urgent and therefore did not offer assessments on the Bank Holiday, when Mr A was admitted.

33. Our adviser told us that because Mr A was admitted with possible spinal cord compression, he would not have received physiotherapy until after staff had received the results of his MRI scan. They also said that the medical notes reflect that physio was delayed because Mr A had deep vein thrombosis, which is where a blood clot forms in a deep vein, usually within the calf or thigh. They said that staff did not class Mr A as urgent, as urgent patients are usually those who need to return home as soon as possible or need chest physiotherapy. They told us that there was a low likelihood that the delay in Mr A receiving physiotherapy impacted his mobility or, in turn, caused his pressure ulcers to deteriorate.

34. We understand why Mrs A has questioned if the delay in Mr A receiving physiotherapy impacted his mobility and in turn led to a deterioration in his pressure ulcers. We have seen no indications that staff got anything wrong in how they prioritised Mr A for physiotherapy and when he received physiotherapy, although we appreciate why it felt delayed to Mrs A. We hope that Mrs A is reassured that it is unlikely the delay in Mr A receiving physiotherapy impacted his mobility or caused his pressure ulcers to deteriorate.

Communication of Mr A’s prognosis

35. Mrs A told us that she and Mr A were told of Mr A’s twelve-week prognosis in a public, busy ward where everyone could hear. Mrs A said that rather than pulling a curtain around the family to share the news, the staff could have moved Mr A’s bed to another room for privacy. Mrs A told us it was unprofessional and was a very upsetting way to hear Mr A’s prognosis.

36. The Trust said it was sorry for the unempathetic way Mr A’s prognosis was shared by their oncologists,. It said that all staff receive training in advanced communication to help them manage conversations like these with compassion, and that they expected every interaction to reflect this training.

37. During our investigation the Trust told us that sensitive conversations are sometimes required in ward environments that offer limited privacy, with only curtain screening available and no dedicated room immediately accessible. While staff endeavour to conduct difficult discussions with dignity and respect, the physical environment can present challenges for both patients, families and staff. It said that as a result of Mrs A’s complaint, the Trust has reflected on the importance of considering whether a more private setting is available when undertaking particularly sensitive discussions and will remind ward teams to utilise private rooms where possible and available.

38. We do not doubt that this was an uncomfortable and upsetting experience for Mr and Mrs A. Mrs A told us that when the curtain was removed, everyone else in the ward was looking at them both and she felt like this could have been avoided.

39. Our NHS Complaint Standards say that organisations should accept responsibility for when something has gone wrong, apologise and express regret, explain how their organisation will use the learning from the complaint in the future and describe what organisations should do to improve services.

40. In line with our Complaint Standards, the Trust has taken appropriate action to make sure that it has learnt from Mrs A’s complaint to improve their service. We consider that in apologising and reminding ward teams to utilise private rooms where possible and available, the Trust has taken appropriate actions to put things right in line with our Complaints Standards.

41. Although nothing can change Mr and Mrs A’s experience, we hope Mrs A feels reassured that this matter was taken seriously and that the Trust has taken actions to prevent what happened to her and Mr A from happening to other people where possible and available in the future.

Complaint Handling

42. Mrs A told us that the Trust’s complaint handling was poor as in its complaint response, it incorrectly said Mr A did not want to move or be moved which would have helped his pressure ulcers, which was upsetting and frustrating.

43. We understand that it must have been difficult for Mrs A to receive a complaint response that she feels does not accurately reflect her and Mr A’s experience.

44. Our Complaint Standards say that organisations should be open and transparent. We recognise that Mrs A’s point of view and recollection differs from that set out in the Trust’s response. But as we have already set out, staff acted in line with relevant guidelines in managing Mr A’s pressure ulcers and there is a lot of evidence to show that Mr A declined to be repositioned on occasion. Therefore it was right that the Trust pointed this out. This demonstrates that the Trust’s response was open and transparent, in line with our NHS Complaint Standards.

45. We are very sorry to hear of the impact Mr and Mrs A, and their daughters experienced during Mr A’s long and difficult hospital stay; we understand that this was very distressing time for all of them. We hope Mrs A is reassured that staff’s care for Mr A’s pressure ulcers and his access to physiotherapy was in line with what it should have been.

1. We are sorry to hear of how difficult Mr A’s hospital stay was for him as well as how distressing it was for Mrs A and her daughters to witness and support Mr A during this time. We acknowledge that Mr A’s hospital stay still weighs heavily on Mrs A as she grieves for her husband. We hope that our work can give Mrs A some reassurances regarding staff’s care for Mr A whilst he was in hospital.

2. There are a number of reasons we will not be investigating this complaint any further. We have seen no indication that anything went wrong in how staff cared for Mr A’s pressure ulcers during his hospital stay. Staff correctly assessed Mr A as high risk given his existing pressure ulcers and introduced interventions in line with guidelines for high-risk patients. We saw no indications that staff got anything wrong in how they prioritised Mr A for physiotherapy and when he received physiotherapy. Importantly we do not think that the delay in Mr A receiving physiotherapy was impacted his mobility or caused his pressure ulcers to deteriorate. Where we do think something went wrong, in the staff’s failure to empathetically tell Mr A and family his prognosis, we think that the Trust has taken actions to put things right as far as possible. We think that the Trust’s complaint handling was in line with the NHS Complaints Standards.