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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 family’s MSP.

Ombudsman found that:

• Patient was assessed as low falls risk on admission

• Patient was not reassessed in line with the board’s 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 board’s procedures after A’s 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




This is an independent website which aims to collect and publish links to information in the public domain relating to falls that have followed failures of nursing care at Forth Valley Royal Hospital and within NHS Forth Valley.

This website is not connected with NHS Forth Valley or Forth Valley Royal Hospital - but it would like to know why patients keep falling, are injured - and sometimes go on to die - after falls on wards where nursing protocols have not been observed properly.

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