Scottish Public Services Ombudsman

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  • Case ref:
  • Date:
    January 2014
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
  • Subject:
    nurses / nursing care
  • Outcome:
    Some upheld, recommendations


Ms C complained that the board had failed to take action to prevent her father (Mr A) from falling while he was in hospital. The hospital had completed a nursing assessment when Mr A was admitted. It was recorded that he was able to walk independently with a stick, but that he needed bed rails. Mr A got up to go to the toilet during the night. The nightshift staff in the hospital found him standing next to the toilet, holding onto the handrail. The next day, staff found that Mr A's mobility had deteriorated. He told them that he had fallen in the toilet during the night. Staff arranged an x-ray and it was found that Mr A had fractured his pelvis.

After taking independent advice from one of our medical advisers, we found that it was appropriate to promote Mr A's independence and that it was reasonable that he was able to go to the toilet alone. Although it was decided that Mr A needed bed rails, the board's guideline for falls management stated that bed rails would not prevent a patient leaving their bed and falling elsewhere, and should not be used for this purpose. Ms C said that her father had told her that the bed rails were not up when he went to the toilet. However, the member of staff who had assisted Mr A when she found him in the toilet recorded that the bed rails were up when she took him back to the bed. Although we recognised that the fall had a significant impact on both Mr A and Ms C, we found that there was no evidence to suggest that it could have been prevented.

Ms C also complained about the board's handling of her complaint. We found that they had delayed in responding, although they had apologised to Ms C for this. They had also failed to provide a full and detailed response to the complaint. We found that they should have tried to address the points Ms C made about whether or not the bed rails were up when Mr A got out of bed. In addition, the response had incorrectly referred to her late mother instead of her father. In view of all of this, we upheld this aspect of her complaint.


We recommended that the board:

  • issue a written apology to Ms C for incorrectly referring to her mother instead of her father in their response to her complaint and for failing to provide a full and detailed response to the complaint.

Download case 201301143 as a PDF (12.58 KB)

Updated: January 29, 2014