Overview
The complainant (Mrs C) raised a number of concerns that her late father (Mr A) received inadequate care and treatment while in hospital being treated for dizziness; a swollen leg; a 'blister' on his left big toe; and a general feeling of being unwell and tired. Mrs C also complained that Mr A's falls risk was not properly assessed and monitored, resulting in a fall that caused a broken hip. Mr A then waited some 54 hours before his broken hip was surgically repaired. Mr A died in hospital nine days after his surgery.
Specific complaints and conclusions
The complaints which have been investigated are that Fife NHS Board (the Board):
- (a) unreasonably failed to reassess Mr A's falls risk when staff were informed that he had already fallen on the ward (upheld);
- (b) unreasonably delayed in taking Mr A to theatre when he fell and fractured his hip (not upheld);
- (c) failed to appropriately manage Mr A's intake of food and fluids (upheld); and
- (d) failed to communicate appropriately with the family following Mr A's death (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) provides evidence that the falls risk assessment policy and procedures on the ward have been appropriately reviewed and any learning points form part of an action plan for improvement;
- (ii) ensures that all nursing staff are fully aware of and trained in compiling falls risk assessments and the on-going monitoring of patients at medium or high risk;
- (iii) reviews their procedures for assessing and monitoring patients awaiting surgery to ensure that a co-ordinated multi-disciplinary team approach is taken;
- (iv) ensures that all staff are made aware of the importance of food and fluid intake management and take appropriate steps to ensure that patients are appropriately monitored;
- (v) remind all staff of the importance of communicating effectively with patients, relatives and/or carers on all aspects of care, including food and fluid management;
- (vi) ensures that all staff are made aware of the importance of good communication with families at all times, especially following a bereavement and considers providing training where necessary;
- (vii) ensures that all staff are aware of the rules on reporting cases to the Procurator Fiscal's Office (PFO) and pass this information on to families where appropriate; and
- (viii) considers making the leaflet 'What to do after a death in Scotland' available where appropriate.
The Board have accepted the recommendations and will act on them accordingly.