Trust did not give patient reasonable care

What happened

Mrs D was admitted to hospital and placed on one‑to‑one nursing care because she was at risk of falling. She fell twice whilst she was in hospital, sustaining a fracture as a result of the second fall. Her health deteriorated and she died just over three weeks after the second fall.

What we found

The Trust took the complaint seriously and conducted a serious incident report. It acknowledged failings to give the planned one‑to‑one nursing care and supervision, apologised and put in place an appropriate action plan.

There was a delay in carrying out the X‑ray that identified a fracture, and a failure to acknowledge that Mrs D's falls contributed to some extent to the deterioration that led to her death. There were unrecognised failings with regard to record keeping.

However, given Mrs D's frailty and general health, we could not say with confidence that she would not have died if she had not fallen.

Putting it right

The Trust apologised to Mrs D's family and took steps to put things right.