Reed v Mid-Essex Hospital Services NHS Trust [29.05.12]

Out of court settlement of £20,000 for failure to identify and treat patient’s pressure sores, which restricted mobility for 14 months prior to death.

Comment

This case demonstrates the importance of ensuring basic observations and nursing management to prevent the development of complications. If the risk of pressure sore development had been recognised and a tissue viability plan implemented the pressure sores which subsequently developed could have been avoided. Hospitals implement protocols to ensure nursing management predicts and prevents problems occurring but the opportunity was missed on this occasion.

Background

The Deceased suffered from chronic vascular disease. In June 2009 he was admitted to a hospital of the Defendant Trust for a suspected left groin haematoma. He complained to the nursing staff about pain in his right heel. However, no action was taken to determine risk of a pressure ulcer (Waterlow assessment) or to place him on a pressure relieving mattress. There were no turning charts in place keeping track of when and how often he was moved.

On 23 June 2009, the Deceased was discharged into the care of the district nurses. Upon examination the following day, a large blood blister was found on his right heel.

On 16 July 2009 the Deceased was readmitted to hospital and was noted to be unsteady on his feet. Following discharge home, he continued to have mobility problems.

In May 2010, the Deceased was assessed by a tissue viability nurse and recommendations were made that he be repositioned every two hours. A wound assessment performed the following month noted a marked deterioration in pressure damage to the right heel, which had developed into a grade 4 pressure sore. A new grade 2 pressure sore was found on his left buttock. The Deceased died in July 2010.

The Claimant (the Deceased’s wife) alleged failure to take any measures to assess and prevent the pressure sores developing during hospital admissions (including a Waterlow assessment in June 2009), failure to inform the district nurses of the pressure sore after his discharge in June 2009 and failure to reposition him every two hours as recommended in May 2010.