County Durham and Darlington NHS Foundation Trust

5. Mrs T complains on behalf of her late Mother, Mrs U, that the Trust allowed a pressure sore to develop between December 2023 and January 2024. Further, she complains the Trust did not communicate with or arrange for any aftercare with the district nurses.

6. Mrs T says Mrs U suffered unnecessary pain which in turn lead to a decline in her health. Mrs T believes pain and distress could have been avoided for Mrs U and the family.

7. As an outcome of her complaint, Mrs T is seeking financial remedy, an apology and service improvements.

Issue 1 – Pressure Sore Development

10. 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 have not found any indications that something has gone wrong.

11. Mrs T says the Trust allowed a pressure sore to develop on Mrs U during her admission between December 2023 and January 2024. Mrs T believes Mrs U should have been better cared for to prevent the development of a pressure sore during her admission.

12. We asked an independent clinical advisor to review Mrs U’s clinical records from the point of admission up until the point of discharge. Our advisor explained that based on notes taken upon admission, Mrs U was admitted into the Trusts care with the pressure sore in question already present. Mrs U’s medical records show Tissue Viability (TV) and Emergency Department (ED) assessments were conducted on 20 December, less than 48-hours after Mrs U’s admission. These assessments both note the presence of a pressure ulcer. Our clinician confirmed that 48 hours is an acceptable timeframe for these assessments to be conducted and a pressure ulcer would not develop within a 48-hour time frame. This confirmed that the pressure sore was already present prior to Mrs U’s admission.

13. The Trust provided care that showed consideration of Mrs U’s fragility. Mrs U was noted as having multiple visits from the TV nurses and was out on a pressure relieving mattress to prevent the development of further sores or the exacerbation of the already present sore.

14. The presentation of the pressure sore upon admission therefore removes the possibility that this sore developed during Mrs U’s stay in hospital. As a result, we cannot identify any failings in relation to this part of the complaint.

Issue 2 – After Care Arrangements

15. Mrs T says the Trust did not communicate with or arrange for any aftercare with the district nurses to care for Mrs U and the pressure sore she had. She believes this worsened Mrs U’s condition and left her in additional and unnecessary pain.

16. We consulted an independent clinical advisor to consider Mrs U’s condition and to advise what measures should have been put in place upon Mrs U’s discharge. Given that Mrs U was admitted into the Trusts care with a pressure ulcer of concern and other vulnerable factors, the Trust should have been considering the conditions at home for Mrs U to return to with the intention of putting something in place to better these conditions to prevent this from happening again.

17. The NICE guidance ‘Transition between inpatient hospital settings and community or care home settings for adults with social care needs’ section 1.5.14 states;

‘The discharge coordinator should work with the hospital and communitybased multidisciplinary teams and the person receiving care to develop and agree a discharge plan.’

18. Further, Section 1.5.17 states;

‘The discharge coordinator should arrange followup care.’

19. These guidelines set out the best practice for clinicians when considering discharging a patient with social care needs. Our advisor explained that Mrs U’s medical records do not provide sufficient evidence to suggest that the Trust established proper discharge plans and support.

20. Mrs U’s discharge documents detail a discussion between the Trust and Mrs U’s family which states the family informed the Trust that once Mrs U was medically optimised for discharge, they do not think she needs any social sorting. Our advisor suggests the clinicians at the Trust should have established more details, particularly surrounding the amount of care the family are able to provide. Given that Mrs U required two clinicians whilst an inpatient, she will have required the same care level at home. There is no evidence that this was established.

21. As a result of identifying these failings, we approached the Trust on 10 July 2026 to discuss the routes to resolving this complaint. The Trust responded on 22 July to confirm that they accepted the recommendations made by PHSO. Further, the Trust is prepared to issue an apology, evidence of service improvements and a financial remedy to Mrs T.

22. The Trust confirmed in email correspondence on 12 August that it had reconsidered the financial remedy it was willing to offer Mrs T. The Trust have confirmed they are increasing financial compensation from £600 to £1,200 in line with the upper limit of our Level 3 financial remedy.

23. Considering the Trusts willingness to provide Mrs T with the outcomes she seeks from this complaint, we now consider that this complaint has reached a satisfactory conclusion in line with Mrs T’s sought outcomes. We spoke to Mrs T on 17 August 2026 to inform her of this outcome. Mrs T had already received communication from the Trust regarding the resolution and was keen for the complaint to be drawn to a conclusion.

1. We have carefully considered Mrs T’s complaint about an NHS Hospital (the Trust) and its failure to prevent a pressure sore from developing and failing to arrange continuing care with district nurses for her mother, Mrs U.

2. We were very sorry to hear of Mrs U’s death. We appreciate how difficult this has been for Mrs T and the wider family. We also acknowledge it must have been very hard to discuss the circumstances of the complaint with us. We are very grateful to Mrs T for the time and effort taken in bringing this complaint to our attention.

3. There are elements of Mrs T’s complaint where we have not seen any indications that things went wrong. This means that from the evidence we have considered, it appears that the Trust provided appropriate care and treatment to Mrs U.

4. Where we have identified indications of service failure in relation to the Trusts aftercare and discharge arrangements with district nurses, the Trust have agreed to provide resolution. Our view is the Trust is now providing resolution to satisfy the outcomes sought from Mrs T’s complaint.