Decision Report 201905289

  • Case ref:
  • Date:
    December 2020
  • Body:
    Forth Valley NHS Board
  • Sector:
  • Outcome:
    Upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis


C complained about the care provided to their parent (A) after A suffered an unwitnessed fall. C said that A had deteriorated continuously from this point, whilst the board said that A had not shown any significant signs of distress until later, when they began to deteriorate significantly. A was transferred to Forth Valley Royal Hospital, where they were found to have fractured ribs and a pneumothorax (collapsed lung). C did not believe that A was examined quickly enough after their fall and considered it unreasonable that the examination had failed to identify the serious injuries A had sustained.

We took independent medical advice. We found that A’s care and treatment fell below a reasonable standard. There was an excessive delay in providing A with a medical examination and there was inadequate investigation of A’s subsequent symptoms. In addition, A’s mental deterioration and existing diagnosis of dementia were not taken into consideration in the assessment of their condition or in the communication with their family.

We upheld both of C’s complaints on the basis that A’s care and treatment was not of a reasonable standard. As the board had concluded staff had followed the board’s procedures after A’s fall, we found that these procedures were not adequate and required review.


What we asked the organisation to do in this case:

  • Apologise to C for the failings identified in A’s care and treatment.
  • Apologise to C for the procedural inadequacies identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at

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

  • National Early Warning Score monitoring should be increased when appropriate, demonstrating that the patient’s condition and medication have been taken into account.
  • Pain in patients with cognitive impairment should be managed effectively, taking their impairment into consideration.
  • Possible delirium should be identified and investigated.
  • Staff should be aware of the potential for a typical presentations of acute illness in frail older people and when further investigation should be considered.

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: December 16, 2020