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Investigation Report 201101660

  • Report no:
    201101660
  • Date:
    September 2012
  • Body:
    Tayside NHS Board
  • Sector:
    Health

Overview
The complainant (Mr C) complained about a significant pressure ulcer he developed after being admitted to Perth Royal Infirmary (the Hospital). Mr C said that the pressure ulcer affected his quality of life because he had to endure an extended period of bed rest.

Specific complaints and conclusions
The complaints which have been investigated are that:

  • (a) Mr C was provided with inadequate care and treatment which allowed him to develop a pressure ulcer (upheld); and
  • (b) there was a failure to deal with his complaint appropriately (upheld).

 

Redress and recommendation
The Ombudsman recommends that Tayside NHS Board:

  • (i) ensure their tissue viability training programme provides education and training for the assessment, grading and treatment of pressure ulcers in line with national guidance;
  • (ii) undertake an audit of wards within the Hospital to ensure pressure ulcer care and management is in line with national guidance and best practice; and
  • (iii) provide details of the outcome of their review of their complaints procedure to ensure investigations are evidence based and undertaken without undue delay.

 

The Board have accepted the recommendations and will act on them accordingly.

Updated: December 11, 2018