Decision Report 201606202

Summary

Ms C, who is an advocacy and support worker, complained on behalf of her client (Mr B) about the care and treatment provided to Mr B's wife (Mrs A) during her admission to the Royal Alexandra Hospital. Mrs A suffered two falls while in the hospital. Ms C complained that the standard of nursing care and treatment provided to Mrs A was unreasonable. We took independent advice from a nursing adviser. We found that, in general, the nursing care was reasonable and the action taken by nursing staff to assess and protect Mrs A against the risk of falls was reasonable. However, the advice we also received was that Mrs A should have been referred to the falls team earlier than she was and that one of the two falls had not been recorded on the computer system which is used to record clinical incidents, such as falls. This computer system is an important mechanism to record incidents so that learning and improvement can take place. On balance, we upheld Ms C's complaint about the nursing care and treatment provided to Mrs A.

Ms C also complained that the medical care and treatment provided to Mrs A was unreasonable. We took independent advice from a consultant in general medicine. We found that, in general, the medical care and treatment was reasonable. However, we also found that the assessment carried out after the first fall was inadequate and that there was no evidence in the medical records that a medical review had taken place after the second fall. In addition, we found that the communication by medical staff was poor and that they had not fully explained the prognosis for Mrs A and their concerns about her recovery. Given the failings identified we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for failing to adequately review Mrs A after her falls, and for failing to adequately explain her prognosis to her family. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Patients should receive a full medical assessment following a fall.

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.