Nurses did not actively try to prevent patient from falling

What happened

Mr A collapsed at home in the spring of 2012 and was admitted to a hospital. Staff carried out various investigations and treatments. Mr A stayed in hospital until his death nearly eight weeks later. A hospital post mortem was done and some organs removed for testing.

Mr A's wife, obtained her husband's medical records and then complained to the Trust about several things. She was upset about a note that a nurse had made of a conversation she overheard between Mr A and Mrs A that staff had told Mrs A that Mr A had only fallen twice when he fell six times. Mrs A also said that Mr A had not received sufficient help with his personal hygiene needs.

In addition, Mrs A subsequently complained to us that, following the post mortem, that the Trust did not test Mr A's internal organs and then lost them.

What we found

It was appropriate for the nurse to have noted the conversation between Mr A and Mrs A. Once contacted by us, the Trust added an addendum to the record, noting Mrs A's view of the event.

Overall, nurses responded to Mr A's personal hygiene needs appropriately.

Nurses did not implement a falls care plan for eight days and there was no evidence that they actively tried to prevent Mr A from falling. This amounted to service failure.

With regard to the post mortem examination, Trust staff examined Mr A's brain, and the organs were legally disposed of, in line with the consent given by Mrs A.

Putting it right

The Trust apologised to Mrs A. It also acknowledged the service failure we found and the impact that had on her.

The Trust prepared an action plan describing in detail what it had done to make sure it had learnt lessons from the failings we identified.

The Trust declined to investigate Mrs A's concerns as she had not complained within 12 months. While the Trust was entitled to refuse to investigate on these grounds, it would have been better if it had asked Mrs A why she had delayed in making a complaint before making that decision.

We partly upheld this complaint.