Decision Report 201803102

  • Case ref:
  • Date:
    July 2019
  • Body:
    Forth Valley NHS Board
  • Sector:
  • Outcome:
    Upheld, recommendations
  • Subject:
    nurses / nursing care


Mrs C complained about the care and treatment given to her late husband (Mr A) while he was a patient at Forth Valley Royal Hospital. Mr A had a history of cancer and his condition was investigated. His results were in keeping with alcoholic hepatitis. Mr C had abnormal liver function results and changes had occurred in his brain as a consequence of his liver disease. He had lost a lot of weight and went on to develop influenza A (a highly contagious viral infection of the respiratory passages).

Mrs C complained that when she visited Mr A in hospital he was often unkempt and dirty. He also experienced an unwitnessed fall but Mrs C said that he was not properly assessed after this. Mrs C felt that Mr A's condition was allowed to deteriorate, and after developing sepsis he died.

We took independent nursing and gastroenterology (medicine of the digestive system and its disorders) advice. We found that on admission, nursing staff failed to complete a Malnutrition Universal Screening Tool (MUST) which, had they done so, would have alerted staff to his malnutrition and prompted further steps (for example referral to a dietician). A falls assessment should also have been carried out earlier in his admission and then regularly after that, particularly after his fall. However, while we found no evidence that he had not been nursed in a dignified way, we found that there had been failures in Mr A's medical care, there was poor documentation and monitoring of his liver disease, insufficient investigation of his fall, and a full sepsis screen had not been carried out. We upheld Mrs C's complaint.


What we asked the organisation to do in this case:

  • Apologise to Mrs C for failing to properly carry out a MUST and falls assessments and for failings in medical care.

What we said should change to put things right in future:

  • A MUST assessments should be carried out on admission.
  • Falls assessments for patients similar to Mr A should be carried out on admission and thereafter at least on a weekly basis.
  • Patients admitted with moderate liver impairment who have a mortality of over one in four should be treated in the correct ward by the correct team as a matter of priority.
  • 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.
  • Medical teams should be aware of the high risk of mortality of patients admitted with decompensated liver disease, including the risk of sepsis.

Updated: July 24, 2019