Mrs Y complained she was not told her mother, Mrs C who was in her nineties, had fallen out of bed in hospital. She was shocked to see her mother's heavily bruised face when she visited. She was also not told when her mother was discharged to a nursing home.
What happened
Mrs C was admitted to hospital from her nursing home with a chest infection. She was confused and partially sighted. She fell out of bed into the gap between the wall and the bed, when a health care assistant was changing her bedding. She suffered severe bruising to her face as a result. The hospital did not tell her daughter, Mrs Y, about the fall. When Mrs Y visited her in hospital, she was shocked and distressed to see the bruising on her mother's face.
The hospital failed to tell Mrs Y that her mother had been discharged from hospital to a nursing home. The hospital also gave Mrs Y incorrect information to Mrs Y about funding arrangements, and failed to tell her that her mother was granted fast‑track funding (NHS funding for patients with a rapidly deteriorating condition that may be terminal).
What we found
The Trust failed Mrs C because she should have been nursed by two members of staff, as set out in her falls care plan. This may have prevented her falling out of bed. The Trust had taken some action in response to this, including raising the issue with the member of staff involved, but did not go far enough. The Trust needed to do more to make sure that staff follow falls care plans.
The Trust failed again when it did not tell Mrs Y about her mother's fall and did not record Mrs C's injuries in her hospital discharge paperwork. Not telling Mrs Y that her mother had been transferred was also a failing, as was giving Mrs Y wrong information about her mother's fast track funding.
There was evidence that the Trust had taken some steps to address the failings. It introduced electronic incident reporting; used ward meetings to tell staff about informing relatives when patients fell; discussed discharge completion summaries at governance meetings, and audited discharge checklists.
Putting it right
The Trust apologised to Mrs Y for failing to take enough action in relation to her mother's fall out of bed.
It produced an action plan that demonstrated that it had learnt lessons from this case, in particular in relation to staff following falls care plans.
University Hospital Southampton NHS Foundation Trust
Southampton
Did not apologise properly or do enough to put things right
Apology
Recommendation to learn lessons or draw up an action plan