BackThe vulnerable partially sighted lady was admitted to University Hospital Southampton NHS Trust with a chest infection and was in a confused state after she left her nursing home. She suffered severe bruising to her face when she fell out of bed, into a gap between the wall and bed, when an agency health care assistant was changing her bedding.
The Parliamentary and Health Service Ombudsman’s investigation found that according to the Falls Care Plan – a plan to manage the risk of the patient falling - she should be moved by two members of staff but she was moved by only one.
The hospital did not tell the woman’s daughter about the fall. When her daughter saw her mum in the nursing home she was shocked and distressed to see the bruising on her face. The hospital also did not record the mother’s injuries in her hospital discharge paperwork. The hospital then failed to tell the daughter that her mum had been discharged from hospital to a nursing home. The hospital also provided incorrect information to the daughter about funding arrangements.
The mother died five days after being discharged to the nursing home. The daughter told the Ombudsman Service her mum’s bruising is an enduring memory of her.
Parliamentary and Health Service Ombudsman Julie Mellor said: “This story shows the importance of following clearly laid care plans. It also highlights the effect poor communication in the health service can have on people. The daughter, on several occasions, was left not knowing what was happening to her incredibly vulnerable mother, which was clearly very distressing for her. The Trust’s poor treatment of her mother has meant she has lost confidence in the NHS.”
The Ombudsman Service has found evidence the Trust has taken steps to address the failings. They have introduced electronic incident reporting, use ward meetings to tell staff about informing relatives when patients fall, discuss discharge completion summaries at governance meetings and audit discharge checklists.
Source: Office of the Parliamentary and Health Service Ombudsman, UK
