Older patient fell at home after Trust discharged her against her daughter's wishes

What happened

Mrs Y had dementia and was visually impaired. She went into North Manchester General Hospital after a fall at home. Staff treated her, and then doctors decided that she was medically fit to go home. A physiotherapist and an occupational therapist then assessed her as at her usual level of mobility. Staff discharged Mrs Y home.

Mrs Y fell at home and fractured her hip. She went back into hospital, where she had another fall. Staff later discharged Mrs Y home. Mrs Y's general health continued to deteriorate and she died after another hospital admission.

What we found

The Trust's response to Mrs G's complaint was mostly appropriate. It acknowledged her concerns and apologised for some weaknesses in the care and treatment it had given. It also developed an action plan to learn lessons from Mrs G's complaint.

Although we found some shortcomings in doctors' assessment of Mrs Y's medical fitness for discharge, the overall handling of her discharge did not amount to service failure.

We found deficiencies by nurses when they assessed Mrs Y's risk of falling, and in how they planned her care. Staff missed opportunities to plan and deliver more appropriate care. However, this would not have prevented Mrs Y's fall. We also found that the doctors' decision not to scan Mrs Y's head after her fall was reasonable.

There were some shortcomings in Mrs Y's personal care. The Trust apologised for some of these.

There was no maladministration in how the Trust handled Mrs G's complaint.

Putting it right

The Trust agreed to write to Mrs G to acknowledge the failings in falls risk assessment and care planning, to apologise for the impact of these, and to update its action plan to make sure that lessons have been learnt.