Decision Report 201601710

Summary

Mrs C complained about the care the board gave to her father (Mr A). Mr A had Parkinson's Disease and was admitted to Glasgow Royal Infirmary as he had fallen a few weeks before and had become confused and unable to cope at home. Mrs C said that shortly afterwards, he became constipated and was given an enema. She said that he was then left alone and when he attempted to go to the bathroom, he had fallen out of his bed which had the side rails raised. He broke his hip. Mrs C complained that if Mr A been properly assessed on arrival at hospital and properly supervised after the enema, he would not have broken his hip. She also complained that after the accident, he was not given appropriate physiotherapy treatment.

Mrs C complained to the board who agreed that there had been shortcomings with regard to Mr A's care. They said that a falls and bedrails assessment should have been carried out in a timely way and they should have ensured that Mr A understood the instructions he had been given about the enema. They apologised and put procedures in place to try to avoid the same thing happening in the future. However, with regard to physiotherapy, they said that as Mr A's condition had plateaued, it had come to an end.

We confirmed that there had been shortcomings in Mr A's assessments regarding falls, bedrails and cognitive condition. Although a comprehensive care plan was put in place, this should have been within 24 hours of Mr A's admission. Had this been the case, the risk of him falling may have been minimised or prevented. However, we further established that procedures with regard to the enema had been reasonable, as had Mr A's physiotherapy.

Recommendations

We recommended that the board:

• demonstrate to us the processes put in place as a result of Mrs C's complaint.