Decision Report 201607464

  • Case ref:
  • Date:
    December 2017
  • Body:
    Forth Valley NHS Board
  • Sector:
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis


Mrs C complained about the care and treatment provided to her late mother (Mrs A) at Forth Valley Royal Hospital. Mrs A was admitted to the hospital following a collapse at home. During her admission, she fell and sustained serious injuries. Mrs C believed that the fall in hospital contributed to Mrs A's death a few days later, and that healthcare professionals failed to take appropriate action to minimise the risk of Mrs A falling, particularly in light of her complex medical history. Mrs C also raised concerns about complaints handling issues, including a failure to respond thoroughly and a delay.

We took independent advice from a nursing adviser who specialises in falls prevention and a medical adviser who specialises in acute medicine. We found that, while there was evidence that nursing staff had highlighted Mrs A's risk of falling and had put in place a number of interventions to address it, there were shortcomings in this. Mrs A's condition deteriorated shortly before her fall and we found that a further review of her needs should have been carried out then. We also found that, in the lead up to the fall, the amount of time that Mrs A was left on a commode with little supervision was excessive. Having said that, the advice we accepted was that the fall did not directly lead to her death. On balance, we upheld this aspect of Mrs C's complaint.

With regards to Mrs C's concerns about complaints handling, we found that the board's investigation was thorough and their position that they could not give Mrs C a definitive account of how Mrs A fell because nobody saw it was reasonable in the circumstances. However, we upheld the complaint because the time it took the board to respond to Mrs C was unreasonable.


What we asked the organisation to do in this case:

  • Apologise to Mrs C for failing to take all reasonable steps to minimise the risk of Mrs A falling.
  • Apologise to Mrs C for failing to deal with her complaint within a reasonable timescale.

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.

Updated: March 13, 2018