Summary
Mrs A was an elderly woman with cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember). She was admitted to hospital in April 2011 after falling at home and had an operation to repair a fractured hip. Mrs A developed an abnormally large volume of fluid in her feet and ankles and a leg infection. In July 2011, she was transferred to another hospital for treatment but was considered too frail for an operation and returned to the first hospital several days later. Mrs A was transferred to a third hospital at the end of August and died several months later. Mrs A's daughter (Ms C) complained about numerous aspects of her mother's care and treatment, including wound management and treatment, falls prevention, loss of hearing aids and teeth, the suitability of the ward and failure to carry out a Doppler test to assess her blood flow.
Our investigation found that the care and treatment in relation to wound management and treatment, the suitability of the ward, and failure to carry out the Doppler test was reasonable. There was no evidence to suggest that a Doppler test should have been carried out earlier, and the tissue viability nurse visited Mrs A at frequent intervals, documented their assessments and plans and took into account the overall requirements of Mrs As health and wellbeing. On the loss of hearing aids and teeth, we recognised the impact of this on Mrs A, but we were unable to establish how these were lost. It can be very difficult to prevent the loss of such items and we found staff took reasonable action to find and replace them. However, in relation to falls prevention, we found that the hospital failed to adequately risk assess, keep the assessment under review or have a cohesive falls prevention plan as part of the overall care plan.
Recommendations
We recommended that the board: take steps to ensure that ward staff comply with guidance on falls prevention; and apologise to Ms C for the failures identified.
Related reading
View Decision Report 201104107 as a PDF (13.07 KB) Updated: March 13, 2018