Decision report 201005072

Summary
Ms C complained about the treatment her sister (Mrs A) received following a fall. Mrs A suffered from early onset Alzheimers disease and fell at home injuring her face and chest. She attended an Accident and Emergency unit (A&E) but was discharged without having had x-rays or a CT scan. Ms C complained about what she saw as inadequate investigation of her sister's injuries and a lack of timely pain relief or follow-up treatment. She also complained about the board's complaints handling and the fact that Mrs A was denied access to the Falls Team because she was under 60 years of age, which was apparently the minimum age to be able to access this service.

After taking advice from one of our professional medical advisers we upheld all of Ms C's complaints. Although our adviser confirmed that x-rays and a CT scan were not in fact necessary, we found the board's investigation of Mrs A's injuries inadequate, as they did not follow national Scottish Intercollegiate Guidelines Network (SIGN) guidance on the observation of head injuries. We also found that the board's policy was in fact to allow patients under the age of 60 to access the Falls Team if this was clinically indicated. The policy, however, was not followed on this occasion. We found that the discharge planning process was inadequate and that there were inaccuracies in the board's response to Ms C's complaint.

Recommendations
We recommended that the board:
• apologise to Mrs A's family for the delay in providing her with appropriate pain relief;
• remind staff in A&E of the need to both establish and adequately record the criteria for discharge following head injury contained in SIGN Guidance 110; and
• re-emphasise to complaints handling staff the importance of having an informed clinical review of complaints responses before they are issued.