Mrs A raised concerns that staff failed to properly assess and treat her mother’s (Mrs B) leg ulcers following admission to hospital. These ulcers had previously been managed well at home through daily visits by district nursing staff. Swansea Bay University Health Board (“the Health Board”) had accepted some shortcomings in the leg ulcer care but was of the view that no harm had resulted from these.
After the complaint to the Ombudsman, the Health Board reconsidered its initial decision that no harm had been caused to Mrs B. This was due to photographs from the District Nursing department which were provided by Mrs A. On the basis of these, the Health Board referred the issues raised to its Legal Department under the redress process. The Ombudsman did not therefore consider the clinical aspects of this complaint. However, the Ombudsman noted that poor communication with Mrs A about her complaint, and the Health Board’s failure to obtain and consider relevant information (District Nursing clinical photographs) in investigating the complaint unnecessarily delayed and escalated the complaint. The lack of availability of Tissue Viability nursing staff was also a concern. In recognition of the poor handling and investigation of Mrs A’s complaint, the Ombudsman upheld the complaint.
The Ombudsman made several recommendations, including that the Health Board should: · Apologise to Mrs A in writing.
· Review its current Tissue Viability nursing provision.
· Review the complaint handling in this case to ensure that all appropriate information proportionate to a complaint investigation is obtained prior to a decision being reached.