Decision report 201201017

Summary

Ms C complained that there was a lack of appropriate care and treatment for her late mother (Mrs A) after she fell while in hospital. Mrs A had been admitted to hospital five days previously because she had fractured her wrist and pelvis. Ms C said that the board's decision not to x-ray her mother and to proceed with her planned discharge on the day she fell was unreasonable. Ms C also raised concerns that staff refused her mother's request to use a zimmer frame immediately before she fell, and that she did not receive adequate pain relief. In response to the complaint, the board advised that it had been appropriate to discharge Mrs A, on the basis of the clinical assessment that had been carried out.

After taking independent advice from one of our medical advisers, we did not uphold Ms C's complaint. Our investigation found that there was evidence to show that during her stay Mrs A had progressed from being able to use a zimmer frame around the ward to using one elbow crutch with the assistance of a member of staff. We considered that appropriate examinations had been carried out by three different doctors, who all agreed that Mrs A could be discharged. In addition, Mrs A's mobility was assessed twice after her fall and although it was noted that she had pain, she was able to weight bear and walk several metres. There was also no evidence of serious injury to suggest that an x-ray should be carried out. However, we took the view that Mrs A's family could have been better involved in the decision to discharge her. We also identified that, whilst Mrs A was given appropriate pain relief, there was insufficient evidence to show that her pain levels had been adequately monitored between the time she was admitted to hospital and her subsequent discharge.

Recommendations

We recommended that the board:

• ensure that relevant staff on the ward clearly monitor and assess a patient's pain using the recognised measurement chart.