Summary
C complained about the care and treatment provided by nursing staff to their late sibling (A), who was admitted to hospital with a chest infection. A was discharged with injuries and delirium, which C believed was due to a fall they had shortly after admission. A was a wheelchair user and especially vulnerable to falls because of their bone condition (osteoporosis). C said that a full assessment of A’s risk of falling was not carried out and that the fall caused A to deteriorate, and led to their death three months later.
We took independent advice from a registered nurse adviser. We found that the standard of nursing care provided was not reasonable in that a falls risk assessment was not carried out fully and accurately, documentation and record keeping did not meet the required standards, communication needs were not met and full learning and improvement was not achieved because a significant adverse event review was not carried out. We upheld the complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to C for the failings identified in this investigation in relation to the standard of nursing care and treatment and complaint handling. 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: Patients who are at risk of falling should have a full falls risk assessment and all appropriate interventions to reduce the risks as much as possible. Families/carers should be informed of a patient’s fall within a reasonable time. Documentation and recordkeeping should meet the required standards. Adverse event reviews should be carried out in line with the relevant framework.
In relation to complaints handling, we recommended: Complaints should be investigated fairly and fully and in line with the requirements of the NHS model complaints handling procedures. Complaint responses should be accurate, complete and address all the points raised in line with the NHS model complaints handling procedure. We offer SPSO accreditedComplaints Handling training. Details and registration forms for our onlineself-guided Good Complaints Handling course (Stage 1) and our onlinetrainer-led Complaints Investigation Skills course (Stage 2) are available athttps://www.spso.org.uk/training-courses.
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.
Related reading
View Decision Report 202409771 as a PDF (27.49 KB) Updated: May 20, 2026