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July 14th 2021

Medical Negligence

Failings over pressure sores leave cancer patient in pain for last few months of her life

Emma Stone

Emma Stone

Solicitor, Clinical Negligence

Failings over pressure sores leave cancer patient in pain for last few months of her life

A 71-year-old woman with cancer was left in significant pain and discomfort for the last few months of her life after hospital failings resulted in her developing pressure sores.

A 71-year-old woman with cancer was left in significant pain and discomfort for the last few months of her life after hospital failings resulted in her developing pressure sores.

The woman was admitted to the accident and emergency department at her local hospital on January 23, 2020 for symptoms relating to her cancer.

It was decided she needed to undergo stenting under the Hull University Hospitals NHS Trust, and on February 2, 2020 she was transferred to Castle Hill Hospital in Cottingham, near Hull.

Despite it being noted on admission that the woman was at high risk of developing pressure sores, there were a number of missed opportunities to action these risk factors, including a missed opportunity to complete the required paperwork and provide pressure relieving equipment. There were also numerous occasions where the woman was not repositioned in line with her care plan.

This led to the woman developing pressure sores to her sacrum and tail bone causing her additional pain and discomfort until her death, due to her cancer, on June 3, 2020.

A Serious Untoward Incident investigation (SUI) was carried out by Hull University Teaching Hospitals NHS Trust, which noted a number of failings in the woman’s care between February 2 and 20, 2020.

Emma Stone, clinical negligence solicitor at Hudgell Solicitors who represented the woman’s widower in this claim, said: “The letter of response from the trust admitted, in line with the serious incident report, that there was a failure to properly action the recognised risk factors in relation to the woman’s care.

“It also admitted that her care plan and the provision of anti-pressure equipment were not properly implemented upon admission leading to further missed opportunities during her inpatient stay.

“Furthermore, it was admitted that on the balance of probability, with appropriate care, the woman’s risk of pressure sores would have been reduced, and any pressure damage would have been identified and treatment commenced earlier.

“An apology was expressed to my client and his family and, due to the hospital carrying out an SUI investigation and making early admissions, we were able to settle the matter within 18 months.”

The trust admitted both breach of duty and causation and the claim was settled for £25,000 in damages.

In the letter of claim, Hull University Teaching Hospitals NHS Trust was asked to concede liability based on the findings of their serious incident report.

The report found that:

  • On February 3, 2020 there was a missed opportunity to action the recognised risk factors that the woman’s skin was at risk of deterioration due to her reduced mobility, medical condition, and nutritional status.
  • On February 3, there was a missed opportunity to have commenced a ‘SSKIN bundle’ (which aids in the assessment and care planning for patients at risk of pressure sores) and implement a plan of care and provide pressure relieving equipment noted on admission.
  • On February 4, a moderate risk care plan was indicated; however, no individualised plan of care was formed. This plan would have given consideration to whether a ‘SSKIN care bundle’ was required along with whether the woman’s pressure preventing equipment was appropriate. It has been agreed by the panel that this should have been undertaken and had it been correctly completed it would have reduced the risk of the woman developing pressure damage.
  • On February 5 and 6, there were sustained periods of time where the woman remained in the same position which did not follow her care plan of being repositioned every two hours.
  • There was a failure on February 7, when the skin discolouration was noted, to complete a wound chart.
  • There was also a failure on February 7 to communicate the injury to the medical and multidisciplinary team and document a care plan as per the high-risk care plan for tissue viability.

Following her discharge from Castle Hill Hospital, the woman was transferred back to her local hospital where she was referred to the tissue viability nurses for future planning. The woman was discharged home just over a week later with a referral to the district nurses for care of the pressure sores.

The woman was set to undergo daily wound management from the district nurses; however, due to the Covid-19 pandemic a decision was made to reduce this to every other day.

“Due to the trust breaching its duty of care, the lady developed three pressure wounds, causing her significant discomfort impacting her daily life,” added Ms Stone.

What are pressure sores and can you make a medical negligence claim?

Following this pressure sores compensation case, Michelle Nurse, solicitor in our clinical negligence team at Hudgell Solicitors, has written an advice blog about pressure sores. Read more here >> 

Watch our video guide to pressure sores

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