A hospital trust failed in its duty of care to a female patient in her 90s who died five days after falling out of bed while the sheets were being changed. The trust also neglected to inform the daughter that her mother had been discharged to a nursing home.
The 95 year old, and also partially sighted woman, was in a confused state when taken from her nursing home to be admitted to University Hospital Southampton suffering with a chest infection. When an agency health care assistant was changing her bedding, the elderly patient fell through a gap between the wall and bed, and suffered severe bruising to her face.
The daughter only became aware of her mother’s injuries when she next visited the nursing home. Along with nursing care staff, she was shocked and distraught at the negligence and lack of care provided to her ailing mother.
A subsequent investigation by the Parliamentary and Health Service Ombudsman found that the hospital had failed to observe a procedure known as the Falls Care Plan. According to the plan, the risk of a patient falling from their bed is to be managed by two members of staff. In the present case, only one care assistant attempted to carry out the task.
It was also revealed that not only did the hospital fail to inform the daughter that her mother had fallen out of bed and later discharged to the nursing home, the mother's injuries were not recorded in her hospital discharge paperwork.
The daughter was also unhappy with the care her mother received and the length of time it took to for her to be discharged, commenting that the hospital was “incompetent” and “sorely” lacking basic nursing and common sense.
The Ombudsman has asked the hospital trust to apologise to the daughter for failing to take enough appropriate action. A hospital trust has a legal ‘Duty of Candour’ to both inform and apologise to patients if mistakes have been made while in their care and which led to significant harm.