A woman suffered “avoidable” pain and distress due to “extremely poor” care of her injured leg at two Aberdeen hospitals, a watchdog has said.
The patient, who later died and who has not been named, was in Aberdeen Royal Infirmary and Woodend Hospital between December 2016 and March 2017 while she had surgery to treat heart disease.
However, the woman – who also had diabetes – suffered significant delirium and a stroke after her operation and she also had a leg wound that became infected.
After she died in March 2017, her daughter complained to NHS Grampian about her mother’s treatment – but the board said appropriate specialists made reasonable decisions about her treatment.
A complaint was then made to the Scottish Public Services Ombudsman (SPSO), which has recommended NHS Grampian make several changes.
A new SPSO report said: “We found that while she was in ARI, some of her post-operative problems could have been expected in someone with her complex health and overall frailty.
“However, insufficient attention had been paid to her symptoms of delirium in relation to her more surgical complications despite them causing the woman significant distress.
“There were delays in referring the woman to the tissue viability team, her wounds were not attended to frequently enough and inappropriate dressings were used.”
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It added: “While we found the woman’s medical care improved when she was initially transferred from ARI to Woodend Hospital for rehabilitation and more attention was paid to her delirium, the nursing care of her leg wound remained extremely poor and caused the woman pain and distress which were all avoidable.
“Finally, we found there had been a lack of information given to the family by ARI about the woman’s delirium and little to no evidence of discussion between nursing staff and the family.
“This was an extremely distressing time for the woman, which was compounded by a lack of information.”
SPSO recommended NHS Grampian apologise to the woman’s family, improve care of patients with delirium and remind staff to communicate clearly with patients’ family.
An NHS Grampian spokeswoman said: “It is clear we let down the woman during her treatment. It is also clear we let down her family when they raised concerns with us.
“We accept the decision and recommendations of the Ombudsman and will be complying with them.
“We apologise unreservedly to the family.”