Summary
C complained about the care and treatment that the board provided to their elderly parent (A). A was an active and independent adult who tripped in the community and was admitted to hospital. In hospital, A developed a grade 4 (most severe) sacral (lower back) pressure sore. The board treated A’s pressure sore using Negative Pressure Wound Therapy (NPWT). A deteriorated while in hospital and died approximately twenty weeks after they were admitted.
C raised concerns about the medical and nursing care that the board provided to A. In particular, C was concerned about how the board handled A’s deterioration in hospital, that there were missed opportunities to discharge A from hospital and A’s end of life care.
The board said that A’s mobility was limited due to pain after admission and that there were no missed opportunities to discharge A. The board apologised for delays in obtaining pressure-relieving equipment for A and that discussions with A regarding the commencement of NPWT were not fully recorded. The board shared an improvement plan regarding the care of pressure sores.
We took independent advice from a consultant geriatrician (medicine of the elderly) and a registered nurse. We found that the medical care provided to A was reasonable. We did not uphold this point of C’s complaint. We found that A’s pressure sore was avoidable. We also found that the board failed to provide reasonable nursing care and treatment to A, failed to reasonably assess and treat A’s wounds, failed to reasonably use NPWT in A’s case and failed to complete a significant adverse event review and follow duty of candour procedures in response to A’s avoidable pressure sore. Therefore, we upheld this point of C’s complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to C for failures in nursing care identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
What we said should change to put things right in future: Negative Pressure Wound Therapy should only be applied where appropriate and in accordance with manufacturers guidance, board policy and Health Improvement Scotland Guidance.
Where failings occur, they should be acknowledged and appropriate action should be taken in line with relevant legislation, policies and procedures (particularly duty of candour and adverse event policy).
Nursing staff should make sure patient’s physical needs are assessed and responded to.
Patients should receive appropriate and timely wound care in line with the patient’s presentation. In particular: Assessments should be completed holistically and on a timely basis, including any required referrals, and should appropriately document the progression/deterioration of a wound; Treatment of the would should be appropriate using the correct products for the type of wound; and Patients should receive appropriate treatment for pressure damage in line with relevant guidance.
In relation to complaints handling, we recommended: Cases involving a death, the circumstances of which are the subject of concern to, or complaint by, the nearest relatives of the deceased about the medical treatment given to the deceased with a suggestion that the medical treatment may have contributed to the death of the patient should be referred to the Procurator Fiscal, in accordance with relevant guidance.
Related reading
View Decision Report 202401128 as a PDF (32.13 KB) Updated: October 22, 2025