NHS Borders have been heavily criticised after an elderly woman broke her hip when she fell out of bed in Kelso Cottage Hospital.
Scottish Public Services Ombudsman (SPSO) Jim Martin said he was “extremely concerned” with the care and treatment the pensioner, named as Mrs A, received from the health authority in February 2009.
The accident resulted in the woman requiring surgery. She had to use of a zimmer frame and take painkillers.
In a damning conclusion to his 18-page report, in which he upheld three complaints from Mrs A’s son-in-law (named Mr C), Mr Martin said: “I have decided there were serious failures in the care and treatment provided to Mrs A, particularly in relation to her fall from her hospital bed.
“In reaching my decision, I have taken into account that the risks of falling cannot be completely eliminated.
“However, despite the fact that Mrs A was admitted to Hospital 1 (Kelso) with a wrist fracture as a result of a fall, and there was further evidence in her clinical notes of her risk of falling, no assessment took place.”
Mr Martin said that the failure of NHS Borders to adequately assess and subsequently review Mrs A’s risk of falling, or draw up a cohesive falls prevention plan, contributed to her accident.
“This led to a significant personal injustice to Mrs A, in that she sustained a significant and potentially life-threatening injury,” added Mr Martin.
He went on: “I am extremely concerned that, notwithstanding their shortcomings, the [NHS Borders] board had a policy and strategy in place which should have been applied to Mrs A, but which was not followed.
“It is also clear that there were significant failures in some of the rehabilitative aspects of Mrs A’s care, relating to nutritional care and multi-disciplinary team working.”
Mrs A was admitted to Kelso Cottage Hospital in January 2009 after breaking her wrist in a fall at home. On February 28, she fell from her hospital bed, fracturing her hip and requiring surgery at Borders General Hospital the next day.
Mr C also complained that there was little communication between healthcare professionals and the family, which adversely affected her recovery.
Upholding the complaint, Mr Martin wrote: “The advice which I have received, and accept, is that the communication fell far below a standard that was reasonable.
“Although Adviser 1 said this did not significantly impede Mrs A’s recovery, it is unacceptable given that effective communication was critical in maximising Mrs A’s chances for a full recovery.”
He also upheld a final accusation that the NHS Borders board had failed to adhere to their complaints procedure, taking more than four months to respond to Mr C’s concerns.
Mr Martin added: “Mr C has complained about the time the board took to deal with his complaint and remained dissatisfied with the explanations the board has provided about Mrs A’s recovery and the failure by the consultant to respond to one of his letters.
“The advice which I have received, and accept, is that the board provided an accurate reflection of the complexities surrounding recovery from hip fractures by older patients with dementia.
“However, it is clear there were some failures by the board in their handling of Mr C’s complaint.”
NHS Borders has apologised for its handling of the case.
Chief executive Calum Campbell said: “NHS Borders fully accepts the recommendation of the SPSO in this case.
“We will be writing to Mrs A’s family with our sincere apologies and an action plan has been developed to implement the recommendations.
“We have assured the ombudsman’s office that we fully recognise, and regret, the aspects of the patient’s treatment and complaint handling which did not meet expected standards and will take what has been learned from this experience to improve our service in the future.”