HEALTH bosses have been forced to apologise after being criticised in an ombudsman’s report over the care of an elderly man who died following two falls in hospital.
An investigation upheld the complaint by the man’s family that the Royal Edinburgh Hospital had poorly assessed his fall risk and failed to care for him properly after the first fall in order to prevent the second one.
The man, named only as Mr A, suffered from dementia and was admitted to the hospital from his nursing home on August 5, 2013, due to worsening behavioural problems, including agitation and aggression.
He was able to walk with a stick when he went into the hospital, but had an unwitnessed fall two days later and suffered bruising. He was found on the floor of his dormitory.
His daughter, referred to as Mrs C, said she had been told he had been assessed as “no falls risk”.
After the fall, it was established he required two walking aids, but Mrs C said she did not believe he was capable of complying with this. She felt this left him at a “very high risk” of falling, as he was likely, due to his agitation, to attempt to walk around the hospital.
She said the family had been told the second fall came as Mr A was standing at the French doors in the day room and tried to turn. He broke his hip and was transferred for surgery but died two days after the operation.
Mrs C had a meeting with staff after the fall and was told one-to-one supervision could be provided, but she felt there was no satisfactory answer as to why that did not happen in her father’s case.
The ombudsman’s report said the investigation of the complaint included obtaining independent advice from a nursing adviser, who noted that the health board’s policy is to complete a falls risk assessment for all elderly patients and to review the patient’s falls care plan if they fall.
“The board’s complaint investigation report said that this was all done, but my adviser found no evidence to support this and considered that the standard of record-keeping and falls prevention practice was poor overall. I agreed with this view and, therefore, upheld the complaint.”
The ombudsman also said the independent advice was “critical overall of the standard of nursing provided to Mr A”.
The record-keeping was “inadequate” and did not include care plans for Mr A’s personal care or communication difficulties. There was also a significant failure to monitor Mr A’s blood glucose levels appropriately and a failure to adequately monitor his nutritional intake.
The ombudsman made a series of recommendations, including that NHS Lothian apologise to Mr A’s family for the failures identified; that it remind all staff a falls risk assessment is a requirement on admission of an elderly patient; and that it remind staff involved in Mr A’s care of the importance of accurate and comprehensive care plans.
Sarah Ballard-Smith, nurse director for acute services at NHS Lothian, said: “I would like to publicly apologise to Mr A’s family for the failings in this case. We recognise that our standards of care fell short and accept the report and its recommendations, which are being put in place.”