NHS Grampian has apologised to the family of a dementia sufferer after “serious failings” in her nursing care were identified.
It comes after an investigation was launched by Scotland’s public sector watchdog following a complaint about the standard of care given to the now deceased woman.
The woman, known only as ‘Mrs A’, was admitted to Kincardine Community Hospital in the Aberdeenshire town of Stonehaven for a period of rehabilitation after a fall.
During her time at the hospital, Mrs A’s son raised concerns about his late mother 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 Scottish Public Services Ombudsmn (SPSO) has 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 report released yesterday, the ombudsman said that Mrs A’s care was found to be “random and left to chance” and overall “very poor”.
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.
“We also found that the pelvic fracture incident had not been recorded as it should have been and there were failures in communicating with Mr A concerning aspects of her care.
“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.”
The ombudsman also found that, although NHS Grampian had apologised to the family and carried out an investigation, the health board had failed to identify serious failings with Mrs A’s care.
The SPSO rated the board’s handling of the complaint as “poor”.
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 yesterday that 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.”
