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Case ref:201508270
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Date:May 2017
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Body:Lothian NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained on behalf of her brother (Mr A), that staff at the Royal Infirmary of Edinburgh failed to ensure he was safely transferred to a trolley. In addition, Mrs C raised concern that the incident was not properly investigated, that Mr A was not reviewed following the incident, and that the complaints handling by the board was poor.
We took independent medical advice. We found that Mr A was not transferred to the trolley in accordance with the moving and handling plan that had been put in place following his mobility assessment. Furthermore, when the incident was reported to a nurse later that evening, we were critical that the nurse did not take appropriate steps to formally record the incident on the hospital's system for reporting adverse events. We considered this would likely have resulted in the incident being investigated in a timely manner, and that Mr A would have been reviewed by a doctor sooner. We were also critical of the board's handling of the complaint. Specifically, that they had inaccurately said that a nurse had been present at the time of the trolley transfer for which they apologised. We also found that the board had not acknowledged that the porter's recollection of the transfer was contrary to the manual handling plan documented in Mr A's clinical records. We therefore upheld the complaint.
Recommendations
We recommended that the board:
- apologise to Mr A for the delay in reviewing him after the incident was reported to the nurse;
- share these additional findings with the nurse involved;
- take steps to ensure that porter staff are made fully aware of patients' mobility limitations and needs prior to carrying out inter-departmental transfers; and ensure that nursing staff are available to provide the necessary support indicated in mobility assessments;
- apologise to Mrs C for the additional failings in the complaints handling identified in this investigation; and
- provide evidence of the steps taken to address the issue related to the complaints handling.