Trust did not arrange a CT scan after an elderly patient fell in hospital

Mrs L was admitted to hospital after falling at home. During the early part of her admission, staff gave her medication that she had taken previously but had stopped taking because it made her confused. Mrs K became concerned about her mother's confusion and it was only when she asked that she discovered that her mother had been given the medication. It was stopped and Mrs L improved again.

After a week in hospital Mrs L was found on the floor at the end of her bed, apparently having tried to climb over the bed rails to get out. She was seen by a doctor and monitored throughout the day. Later that evening her condition deteriorated. Nurses called Mrs K and told them that, although they had initially planned to perform a CT scan, there was by then little point. Mrs L died a few hours later.

A post mortem identified a bleed on Mrs L's brain. The report said it was more likely that the bleed had caused her fall, rather than the fall causing the bleed.

Mrs K complained to the Trust. It accepted it had used bedrails for Mrs L, when it should not have done so.  It also accepted it was a mistake to have given Mrs L the medication, adding that it had given her another medication in error too.

Mrs K complained to us because she wanted apologies, an independent review of her mother's care, service improvements and a payment.

What we found

We partly upheld Mrs K's complaint. The Trust had appropriately addressed Mrs K's complaint about the use of bedrails in her mother's care, but we identified other failings in her mother's medical management.

The Trust should have logged the wrongly given medication as clinical incidents. The first medication may have caused Mrs L's confusion, but did not delay her discharge from hospital. The second medication may have contributed to the bleed on her brain.

As the Trust did not perform a CT scan when Mrs L was first admitted to hospital after her fall at home (a significant failing in itself), we could not say if there was a bleed on her brain before she fell in hospital. Because of this and the post mortem result we could not say that the fall had caused Mrs L's death.

Putting it right

The Trust acknowledged the failings we identified and apologised to Mrs K for their impact on her mother's treatment. It drew up plans to review when clinical incidents are reported and when CT scans should be taken.