Decision Report 201703562

Summary

Ms C complained on behalf of her mother (Mrs A). Mrs A was discharged from Gartnavel Hospital and then re-admitted two days later with a urinary tract infection and fluid on her lungs. Ms C complained that the board failed to discharge Mrs A in a reasonable way.

We took independent advice from a consultant in acute medicine and from a nursing adviser. We found that, medically, it had not been unreasonable to have Mrs A discharged. While she may have had both a urinary tract infection and fluid on her lungs at the point of discharge, these were not doing her harm at that point. However, we found that Mrs A's risk of falls had not been adequately assessed prior to her discharge, and that this risk had also not been adequately communicated to Ms C. We noted that more should have been done to assess and reduce Mrs A's risk of falling before she was discharged, and that it was unreasonable to have discharged her due to her mobility issues. We, therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Mrs A for failing to assess Mrs A's falls risk prior to her discharge, and for failing to communicate this risk to Ms C. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients at high risk of falls should be adequately assessed prior to discharge. Plans should be put in place to manage a patient at high risk of falls prior to their discharge.