Family left not knowing whether a woman would have fallen in hospital if nurses had properly assessed her

What happened

Mrs N (who was in her eighties) collapsed at home and was admitted to her local hospital. Two nights later she was found on the floor beside her bed and told nurses she had fallen. The nurses asked for a doctor to attend but it took around six hours for this to happen. Mrs N was later found to have fractured the upper part of her left thigh bone. Mrs N had surgery to repair the fracture but she died two weeks afterwards.

Mrs N's family complained to the Trust about how the fall was allowed to happen. They said Mrs N had suffered from pain and discomfort because of a series of errors. The evidence shows that the Trust was aware of failings in care and treatment but it did not share this with Mrs N's family, even when they complained. A coroner's inquest was critical of the care and treatment and concluded that Mrs N would not have died on the day that she did 'but for the fracture'.

What we found

The standard of care provided for Mrs N fell below the relevant standards for managing the risk of her falling and managing her pain. In addition, the Trust did not provide adequate responses to the family's complaint. It did not acknowledge failings that it had identified or tell them about the changes these had led to. It also failed to apologise for the failings, even after they had been highlighted during the coroner's inquest.

We could not say that Mrs N's death was avoidable but the risk of her falling and of her suffering an injury following a fall could have been reduced. She was also left in unnecessary pain. The family will never know whether Mrs N would not have fallen, or suffered the fracture, if her risk of falling had been properly managed. The Trust's poor complaint handling led to the family feeling that the Trust did not accept accountability for what had happened, and gave them the impression that their complaint had not been taken seriously.

Putting it right

The Trust has apologised for its failings and has paid the family £500 compensation. It has already taken steps to address the failings in care and treatment identified, and has produced an action plan in relation to the way that it handled this complaint.