Insufficient staffing levels caused distress

What happened

Mr M was admitted to hospital after he tripped and banged his head. Staff diagnosed him with a subdural haematoma (blood between the skull and the surface of the brain) but he was too unwell for surgery. Mr M was admitted to a complex needs ward where there were a number of confused patients wandering and causing disturbances. During his admission, Mr M had two falls. A CT scan then showed that the subdural haematoma had grown. Mr M sadly deteriorated and died in hospital.

Mrs M complained that her husband should never have been admitted to a ward with so many confused patients because he needed a restful environment to recover. Mrs M said that the chaotic atmosphere was distressing for Mr M and the whole family. Mrs M also said that Mr M's falls were preventable and directly led to his deterioration and death. Mrs M also complained that staff left Mr M sitting out of bed for too long, and did not give him intravenous fluids when she asked for them. Mrs M believed that her husband would have recovered from the subdural haematoma if he had received better care and treatment.

What we found

We partly upheld this complaint.

It was reasonable for Mr M to be admitted to a complex needs ward. However, there were not enough staff at the time to meet the needs of all the patients and this was a failing. Although nursing staff raised this issue, the Trust did not take any action. This created a chaotic atmosphere, which was distressing for Mr and Mrs M.

Mr M's falls were probably not avoidable, but there was a lack of one–to–one supervision between the first and second falls, and this was a failing. Mr M was left out of bed for too long. We could not link either of these failings to Mr M's deterioration and death.

It was reasonable not to give intravenous fluids when Mrs M requested them because Mr M was not dehydrated and could drink normally.

Putting it right

The Trust produced an action plan that showed what it had learnt from this complaint to prevent the failings happening again.