|
Ombudsman
upholds complaints and makes
repeated recommendations after
failures of falls care within NHS
Forth Valley
|
Posted
June 25, 2022
|
Forth
Valley Royal Hospital was
officially opened by Queen
Elizabeth on July 6, 2011.
Since
then, the Scottish Public
Services Ombudsman (SPSO) has
made repeated investigations into
complaints about falls prevention
and post falls care within NHS
Forth Valley.
Those
reports have resulted in numerous
findings of poor care.
They
include six separate cases where
patients died after they fell
following failures of falls
prevention care that were later
identified by the
Ombudsman.
The
findings have documented a number
of serious injuries and deaths
sustained after falls where
failures of nursing standards
took place.
The
Ombudsman has recorded a
significant number of violations
of proper falls protocols and
procedures.
The
Ombudsman has made numerous and
repeated recommendations for
improved training and standards
among nurses.
Reports
are summarised below with links
to the SPSO's published
accounts.
|
The
reports that follow are where
failures of nursing care have
been identified and/or
recommendations have been made
regarding falls prevention and
post falls care
standards.
At
time of writing (June 25, 2022),
there are eleven Ombudsman
reports highlighted on this page
- dating from August 2012 to May
2021.
They
include:
- six
cases where patients fell,
sustained a range of injuries
and went on to die after
failures in falls prevention
care and / or post falls
care
- two
cases where patients fell and
broke bones after failures of
falls prevention
care
Dates
shown are dates of the
publication of reports, not of
the incidents:
|
|
August
2012
|
|
Circumstances:
disabled elderly woman
admitted to hospital, where
she fell and broke her
hip
Ombudsman
found that:
Forth Valley Health Board
failed to carry out an
adequate mobility assessment
on admission
The
Ombudsman said: We
recommended that the board
emphasise to staff concerned
the importance of following
and acting upon guidance
available to them concerning
the prevention of
falls.
Link
to
report: https://www.spso.org.uk/decision-reports/2012/august/decision-report-201100965-201100965
|
|
October
2013
|
|
Circumstances:
Female patient aged 94 was
admitted to hospital with
chest and back pain and
shortness of breath.
Family
were assured she would be
discharged within days.
Patient fell, suffered
seizures, developed confusion
and died nine days after
admission.
Complaint
to Ombudsman made by
familys
MSP.
Ombudsman
found that:
Patient was assessed as low
falls risk on
admission
Patient was not reassessed in
line with the boards
policy after she
fell
The
Ombudsman said: We
recommended that the board:
remind staff of the post-fall
protocol outlined in the
in-patient falls resource pack
and the need to properly
record all action taken; and
provide the Ombudsman with
evidence of the additional
training provided to nursing
staff.
Link
to report:
https://www.spso.org.uk/decision-reports/2013/october/decision-report-201204747-201204747
|
|
July
2015
|
|
Circumstances:
patient fell in hospital and
died less than two weeks after
fall.
Patient's
leg was only x-rayed after her
daughter "pointed out to
nursing staff that Mrs A's
foot was at an odd angle and
she was in severe pain". The
x-ray revealed a broken
hip.
The
Ombudsman highlighted the
following failures:
*
Failure to keep nursing notes
in patient's room, which were
then found in another
patient's room, leading to a
delay in pain relief being
prescribed
*
Failure to tell daughter of
her mother's fall - which took
place at 9pm - until the next
morning
*
Incorrect ID information on
patient's wristband
*
Lack of communication with
daughter about what happens
when a patient dies in
hospital.
Link
to report:
https://www.spso.org.uk/decision-reports/2015/july/decision-report-201401085-201401085
|
|
March
2016
|
|
Circumstances:
female patient admitted for
abdominal pain who fell on her
first night in hospital and
sustained numerous
fractures
The
Ombudsman
reported:
*
Fractures not identified for a
week after fall
*
Staff had tried to mobilise
the patient during the period
before fractures were
diagnosed
*
NHS Forth Valley gave "a
number of factual
inaccuracies" in its original
response to a complaint by a
relative of the patient -
including the false claim that
the patient "had been admitted
to hospital following a fall
at home"
The
Ombudsman said: "We also
upheld Mrs C's concerns about
complaints handling as it is
vital that complaint responses
are factually accurate. While
the board have already
apologised for this matter, we
found that they had not
referred to the delay in
acting on the x-ray report in
their response, which we did
not consider to be
reasonable.
"We
recommended that the board:
ensure that our findings are
brought to the attention of
the staff involved in Mrs A's
care and treatment.
"This
should include the adviser's
comments on communication and
the falls risk
assessment."
Link
to report:
https://www.spso.org.uk/decision-reports/2016/march/decision-report-201405636-201405636
|
|
January
2017
|
|
Circumstances:
patient with high levels of
confusion not assessed for
falls risk properly
*
Failings in falls risk
assessment
*
Levels of confusion not taken
into account in falls risk
assessment
*
Failings in nursing care
*
"Unplanned and ineffectively
co-ordinated" communication
with the patient's
family
The
Ombudsman said: "We
recommended that the board:
"Take
steps to ensure that the
impact of cognitive
impairment on patient
safety on the relevant ward
is appropriately assessed
and that measures to
minimise harm are a
prominent aspect of care
plans.
"Apologise...for
the failings identified in
relation to the falls
assessment and care
provided."
Link
to
report: https://www.spso.org.uk/decision-reports/2017/january/decision-report-201600669-201600669
|
|
June
2017
|
|
Circumstances:
patient with high risk of
falls not properly assessed on
two admissions. Patient fell
during time in hospital.
Failures in post falls care.
*
Failings in falls assessments
*
Failings in monitoring
*
Failings in nursing care
*
Failings in falls prevention
*
Delay in review after a
fall
The
Ombudsman said: "What we said
should change to put things
right in future:
"The
board should ensure that
patients at very high risk of
falls should be considered for
referral to a falls
co-ordinator or falls
specialist.
"The
board should issue a formal
apology...for the unreasonable
level of care provided...in
relation to falls assessments,
monitoring and
care."
Link
to report:
https://www.spso.org.uk/decision-reports/2017/june/decision-report-201603071-201603071
|
|
December
2017
|
|
Circumstances:
patient fell during admission,
sustained serious injuries and
died within days.
Patient's
daughter "believed that the
fall in hospital contributed
to (her mother's) death a few
days later."
Ombudsman
reported:
*
"Shortcomings" in falls risk
assessment
*
Failure to carry out review of
needs before fall
*
Nurses left the patient on a
commode "with little
supervision" for an
"excessive" amount of time
prior to her fall.
The
Ombudsman said: "What we said
should change to put things
right in future: all
reasonable steps should be
taken to minimise the risk of
patients falling. 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."
The
Ombudsman said it accepted
advice that the fall "did not
directly lead to her (the
patient's) death" despite
the failings recorded and the
family's view of
events.
Link
to report:
https://www.spso.org.uk/decision-reports/2017/december/decision-report-201607464-201607464
|
|
July
2019
|
|
Circumstances:
patient fell, deteriorated
after fall and died after
contracting sepsis
*
Failure to carry out falls
assessment early enough
*
Failure to update falls
assessment, even after fall
*
Poor documentation
*
Insufficient investigation of
fall
The
Ombudsman said: "Falls
assessments for patients
similar to Mr A should be
carried out on admission and
thereafter at least on a
weekly basis.
All
relevant documentation should
be completed appropriately and
as required.
"Full
assessment and investigation
should be made after a fall,
particularly when the fall
occurs in a patient with liver
failure, into the possible
reasons for the
fall."
Link
to
report: https://www.spso.org.uk/decision-reports/2019/july/decision-report-201803102-201803102
|
|
December
2020
|
|
Circumstances:
patient deteriorated after a
fall.
Ombudsman
identified failings with NHS
Forth Valley's post falls
procedures.
*
staff followed these
procedures after the patient's
fall, the Ombudsman
identified
*
Ombudsman found: procedures
were not adequate
*
Ombudsman ruled: procedures
required review
The
Ombudsman said: "As the board
had concluded staff had
followed the boards
procedures after As
fall, we found that these
procedures were not adequate
and required
review."
Note
- the Ombudsman's report in
this case describes the
patient being "transferred to
Forth Valley Royal Hospital"
where they were found to have
sustained injuries including
fractured ribs and a collapsed
lung. It is not explicitly
stated in the report where the
fall took place, but it is the
case that the Ombudsman said
the board's procedures for
looking after the patient
after the fall "were not
adequate and required
review".
Link
to report:
https://www.spso.org.uk/decision-reports/2020/december/decision-report-201905289-201905289
|
|
February
2021
|
|
Circumstances:
patient who had suffered a
stroke and who had dementia
and delirium fell after being
left unsupervised in the
toilet. Patient suffered
severe head injury and
died.
Falls assessment was carried
out which identified patient
should not be left
unattended
A contracted nurse
left the patient unattended in
the toilet after leaving to
give patient
privacy
Patient tried to get up from
toilet and and fell
The
Ombudsman said: Although
the record-keeping regarding
the falls risk was completed
to a good standard, there was
a breakdown in communication
between permanent staff and
the contracted nurse about the
specific level of observation
required for A. We upheld the
complaint.
Staff
should ensure that when
passing information to others
that full details of the
levels of observation required
are
understood.
Link
to report:
https://www.spso.org.uk/decision-reports/2021/february/decision-report-202001129-202001129
|
|
May
2021
|
|
Circumstances:
patient died after failures in
nursing and medical care
including failures in falls
prevention care
nurses failed to make a falls
risk plan for night/overnight
when patient was at highest
risk of falling.
Ombudsman
said: We also found that
there was a lack of evidence
of regular and appropriate
care rounding to meet A's
personal care needs. We upheld
this complaint.
What
we said should change to put
things right in
future:
If a patient is particularly
at risk of falls at night or
overnight, a clear plan should
be put in place to address
this and it should be recorded
appropriately.
Patients should be given
timely and appropriate nursing
care."
Link
to report:
https://www.spso.org.uk/decision-reports/2021/may/decision-report-201907894-201907894
|
|
|
|