Trust failed to adequately assess and treat older patient

What happened

Mr A fell and cut his head and was admitted to the Trust. Staff found a urine infection and suggested this was the reason he had fallen.

The Trust moved Mr A to a different hospital at the same Trust the next day. Staff at the new hospital told his granddaughter, Ms A, that he also had a chest infection. During his admission, Mr A had several falls and sadly died as an inpatient.

Ms A complained about hydration, how staff managed his confusion, his falls, hospital acquired pneumonia, a delay in staff swabbing a wound Mr A sustained during a fall, and the standard of general nursing care. She also complained that staff attitude, communication and record keeping were poor.

What we found

There was a delay in staff starting antibiotics twice, problems with fluid charts, a lack of detailed assessment of Mr A's cognitive function and identification of delirium on admission, failure to adhere to infection control policy in relation to soiled clothing, failure to appropriately risk assess and manage falls, and failure to adequately communicate with Mr A's family.

However, we did not conclude that these failings caused Mr A pain or distress, or that they contributed to his death.

Putting it right

The Trust apologised to Ms A for the failings identified and prepared an action plan that outlined how it will improve its service for future patients.