NHS Trust’s missed opportunities to treat elderly woman’s pressure sore contributed to permanent nursing home move
A hospital’s failure to properly assess and treat an elderly woman with a pressure sore contributed to her having to move into a nursing home, an investigation by England’s Health Ombudsman has found.
The Parliamentary and Health Service Ombudsman (PHSO) is calling on NHS Trusts to learn from errors and ensure opportunities are not missed to avoid potentially life-changing consequences.
Joyce Musson, 93 from Bideford in Devon, developed a pressure sore at the top of her buttock in 2021.
District nurses from Royal Devon University Healthcare NHS Foundation Trust visited weekly to check and dress the sore, but the visits suddenly stopped on 14 September 2022.
Joyce’s daughter Sarah Musson contacted the Trust on 13 October after the sore deteriorated. A nurse came to clean the sore, but it continued to get worse. Joyce was admitted to hospital on 18 November 2022.
In February 2023 Joyce was discharged to a care home. Joyce previously lived with Sarah and had a degree of mobility. She now requires 24-hour care indefinitely and is mostly bedbound.
Our investigation found that the Trust missed opportunities to treat the sore, which contributed to its deterioration. Despite apologising and putting improvements in place, the Trust did not acknowledge the impact its failure had on the two women.
The Trust also did not follow relevant guidelines to provide Joyce with a consistent wound care plan and dressings.
The missed chances to treat Joyce’s sore and the use of inconsistent dressings contributed to her being separated from her daughter and no longer living independently.
The Ombudsman recommended Royal Devon University Healthcare NHS Foundation Trust acknowledge the failings identified and apologise for the concern, distress and pain caused, and pay £550 in financial remedy. The Trust has complied with our recommendations.
Sarah, 57, said:
“The impact has been awful because mum used to live with me and I looked after her. Now I have to go to the nursing home every day to see her. It’s quite a trip, and life is completely different and not for the better.
“Mum was a nurse. She’s been very badly let down by the NHS. You trust the professionals to look after you when you need help.
“I had all the dressings. I used to go up to the pharmacy and pick everything up so it was all here ready for the nurses. I must have had hundreds of pounds worth of dressings, and nobody seemed to have any clue as to which to use and when.
“We should be confident that nurses are going to look after us to the best of their ability. We’re all human and make mistakes, but those mistakes contributed to mum being in a home.
“I’m very pleased I’ve had the Ombudsman to fight my corner and to speak up for me and mum. The caseworker has been very kind to me, a very patient lady and very good.”
Parliamentary and Health Service Ombudsman Rebecca Hilsenrath said:
“The missed opportunities to provide appropriate treatment in this case have caused distress for Joyce and Sarah. The impact on both of their lives has been significant. Joyce has lost her independence and has been separated from Sarah, and she continues on a daily basis to experience discomfort and pain.
“When mistakes are made, the NHS must take the opportunity to learn and change. They must ensure that errors are properly acknowledged and that they set out what they will do to improve their service. Our casework and recommendations are designed to encourage learning and drive improvements to help build a better healthcare system for all and ensure the same mistakes do not happen again.”
