The family of a north-east dementia sufferer has received an apology from health bosses after an investigation found her care was “random and left to chance”.
The Scottish Public Services Ombudsman has ruled NHS Grampian’s overall care towards the woman, who has since died, was “very poor”.
The woman, known only as Mrs A, was admitted to Kincardine Community Hospital in Stonehaven for a period of rehabilitation after a fall.
During her time at the hospital, Mrs A’s son raised concerns about her developing pressure ulcers.
Mr A and staff at the hospital were also not told for “several weeks” that Mrs A had been diagnosed with a pelvic fracture during a previous stay at Aberdeen Royal Infirmary.
After being discharged, Mr A discovered his mother had developed an ulcer at the bottom of her spine – and had not been told about it.
The SPSO has now made a number of recommendations to the north-east health board regarding record keeping and prevention of bed sores in light of the family’s complaint.
In a judgement to uphold the family’s complaint, the ombudsman said: “We took independent advice from a nursing adviser who said there were serious failings in record-keeping and in compliance with guidance and best practice on the prevention and management of pressure ulcers.
“As a result, Mrs A’s care was random and left to chance.
“Furthermore, although Mrs A was at high risk of developing pressure ulcers, there was a delay in managing her as high risk.
“Overall, the advice we received was that the standard of nursing care provided to Mrs A was very poor and we were critical of those failings.”
Eight recommendations were made to NHS Grampian in the SPSO decision report, including making another apology to Mrs A’s family, feeding back the outcome of the investigation to the staff involved and creating an action plan to address the highlighted issues.
A spokeswoman for NHS Grampian confirmed all eight recommendation had been accepted and implemented in full.
She added: “NHS Grampian fully acknowledges Mrs A’s care and our handling of the subsequent complaint falls short of the standards we aim to achieve.
“We have apologised unreservedly to the family.”
