Trust inadequately assessed patient at risk of falls

What happened

Mrs J has multiple sclerosis (MS) and is paraplegic (paralysis of the legs and lower body). She had a seizure and was found unconscious. She was admitted to the Trust's emergency admissions unit and the next day was transferred to the short stay unit. For the first few days Mrs J refused most treatment and was confused, agitated and aggressive, which was not her usual behaviour. She fell from her bed (she said she must have been dropped because she could not move her legs). She refused examination. Her condition gradually improved and she was discharged after nine days.

At a follow up appointment, a surgeon identified that Mrs J had two fractures (at her knee and ankle) and Mrs J felt these had happened during her fall. Her leg was set bent (with the knee flexed) and she said this made it very hard for her to retain her former independence.

Mrs J complained that as a result of the poor care she received, her quality of life had been affected. She wanted service improvements as a result of her complaint.

What we found

We found no evidence that Mrs J had been dropped. However, we found that her risk of falls had not been adequately assessed and that adequate nursing plans had not been put in place.

We found it was possible that Mrs J's fall had caused her fractures but that it was appropriate for her leg to be set in a bent position. If it had been set with the knee extended (straight), this would have made it difficult for her to move in a wheelchair. We therefore, partly upheld this complaint.

Putting it right

The Trust wrote to Mrs J and acknowledged the lack of risk assessment and apologised for it. It also told us and Mrs J how it was going to make improvements in those areas.