HEALTH bosses have been ordered to apologise to the grieving family of a frail patient who went to hospital with stomach pain but died after falling and breaking her leg.
The Scottish Public Services Ombudsman, Jim Martin, found that nursing staff missed vital warning signs that suggested that the woman was at risk of suffering a fall.
Four days after being admitted to the Capital’s Royal Infirmary, after complaining of lower abdominal pain, the woman asked to use a commode in the early hours of the morning.
She was left alone by nursing staff but fell, breaking her thigh bone. Doctors decided they could not operate, as she had chronic obstructive pulmonary disease (COPD), and she passed away days later.
NHS Lothian told the family that a falls risk assessment had been carried out and that their only failure was that the patient should have been wearing more suitable footwear than socks when left alone.
However, the family referred the case to the Ombudsman, who launched an investigation that uncovered a catalogue of errors.
It was found that the falls assessment had not taken account of the patient’s poor vision, impaired hearing, and potential unsteadiness due to being clinically anaemic and having COPD. The patient had complained to NHS staff of dizziness, particularly when standing up, but it was not considered in the assessment.
The omissions led to an incorrect score being given on the risk assessment. Had she been given the appropriate score, the Ombudsman’s expert advisor said, more measures should have been put in place to prevent the patient falling and to make staff aware the patient was at risk. It was also found that no contemporaneous record of the fall, in March 2012, was made.
Labour Lothians MSP Sarah Boyack said the “tragic” case highlighted the importance of proper assessments of patients when they are admitted to hospital.
She added: “The Ombudsman’s report could not be clearer in its assessment that the health board failed in its duty of care to this patient and her family.
“NHS staff are under tremendous pressure to deliver high standards of care and they must be supported to ensure they have the time to carry out their jobs effectively.
“I hope that the upholding of these complaints allows the family to move on from this devastating incident after two years of fighting for the truth. It is now important that the health board takes the recommendations on board to ensure that similar incidents cannot occur in future.”
The Ombudsman upheld complaints that an appropriate risk assessment had not been carried out and that NHS Lothian had failed to address the family’s concerns adequately after the incident.
NHS Lothian said it had already apologised to the family of the patient and today issued a public apology.
Sarah Ballard-Smith, the health board’s nurse director, said: “We accept the Ombudsman’s recommendations and have already put them into practice by reviewing practices and procedures in relation to falls in hospital and by ensuring that staff understand the importance of accurate and timely record keeping.”