Decision Report 201205000

Summary

Mrs A was diagnosed a number of years ago with early onset dementia. She was admitted to a specialist psychiatric and mental health unit for assessment because of problems with her sleep pattern. During her stay she fell on the ward, breaking her left thigh, and needed a hip replacement in another hospital. Mrs A returned to the unit nine days later and a further 11 days after this fell again, after another patient pushed her. This time she broke her right hip, which also had to be replaced in the other hospital. Mrs A was discharged from there to a nursing home where she is now living. Her daughter (Miss C) complained that Mrs A was provided with inadequate care and supervision while she was being assessed. Miss C also complained that the board's responses to her complaints was inadequate.

We took independent advice from two of our medical advisers. They noted that at times, Mrs A had been on 'constant observations' (where staff were on hand with her at all times) but at other times she was not. The advisers said that Mrs A's mental health condition, falls risk, medication and physical condition were regularly and appropriately monitored and, where necessary, changes were made. Our investigation found that, although it was obviously very unfortunate that Mrs A sustained two fractures within 20 days, her care and supervision were reasonable and appropriate.

On the matter of the complaint responses, our investigation found that all acknowledgements and responses to Miss C's complaint letters were sent within the local and national target timescales. Full explanations were provided and the board acknowledged that this had been a distressing experience for Mrs A and all her family. The board also apologised that in the first response Miss C had not been made aware of the SPSO process. They had not apologised for what happened to Mrs A and Miss C had been concerned about this. We took the view that as we had found that what had happened was not the fault of the board, it was not unreasonable that they did not apologise for this.