Decision Report 202411654

Summary

C complained that their parent (A) suffered a fall while in hospital. C was concerned that bedrails and falls risk assessments were not appropriately completed prior to A suffering the fall. The board said in their complaint response that both bedrails and falls risk assessments had been carried out appropriately.

We took independent advice from a registered nurse. We found that, from the evidence available to us, the falls and bedrail risk assessments carried out prior to A’s fall were limited and did not inform a comprehensive care plan. The board’s Policy for the Prevention and Management of Adult Inpatients Falling in Hospital Settings did not appear to have been followed. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to carry out appropriate risk assessments and care planning prior to A’s fall. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Falls and bedrails assessments should be completed, in full, within 24 hours of admission and reviewed regularly.

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.