Decision Report 201807962

Summary

Mr C complained on behalf of his wife (Mrs A) about a physiotherapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) assessment she underwent. The assessment found that Mrs A could safely use a three-wheeled walking aid outdoors under close supervision. Subsequently, Mrs A suffered a fall while using the three-wheeled walking aid on a downhill slope. Mr C raised concerns that the assessment did not include a slope; it did not assess Mrs A's ability to use the brakes; and that close supervision would not have prevented the accident.

We took independent advice from a physiotherapist. We found that Mrs A's assessment was unreasonable. We found that the record of the assessment lacked appropriate detail. We found it did not address Mrs A's ability to safely negotiate slopes or to use the brakes and that the advice given to Mrs A and Mr C during the assessment was unreasonable. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for the failings identified in her physiotherapy assessment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

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

• Patients' ability to safely use walking aids should be assessed appropriately; both physically and in light of any cognitive impairment they might have. The assessments should then be documented in sufficient detail.
• Patients and their carers should be given appropriate advice on the benefits/risks of using a particular walking aid and appropriate guidance on using it safely. This should then be appropriately documented.

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.