Decision Report 201808024

Summary

Mrs C complained on behalf of her late mother (Mrs A) whose hip fracture was not diagnosed until approximately nine weeks into her hospital admission, following a fall at home and a further fall during her first night in hospital. We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that Mrs A's hip fracture should have been diagnosed within one week of her admission as there was enough information present to indicate she had a fractured hip and more detailed assessments should have been carried out during this time. Therefore, we upheld this aspect of the complaint.

Mrs C also complained that the board did not take reasonable falls prevention measures as Mrs A fell during her first night of hospital, despite having been admitted post-fall, and with a history of falls. We took independent advice from a nursing adviser. We found that there was no evidence that a falls risk assessment was carried out when Mrs A was admitted to the Combined Assessment Unit and there was no evidence of falls prevention measures being put in place at this time, which was unreasonable. Therefore, we also upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified in Mrs A's care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets.

What we said should change to put things right in future:

• Nurses should keep clear and accurate records relevant to their practice, in line with the Nursing and Midwifery Council code.
• Falls risk assessments should be undertaken on patients when indicated.
• When the need for further assessment is identified by therapy staff, this should be notified to appropriate parties and actioned.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.