Inadequate monitoring and discharge after fall

What happened

After the cardioversion, Miss A fell in hospital and hit her head. She was discharged late at night without having been reviewed by a doctor and without having been given a CT scan (CT scans produce detailed images of the inside of the body).

What we found

The hospital failed to write a clear plan to monitor Miss A after the cardioversion, and did not check her often enough.

After Miss A's fall the hospital did not observe her properly.

A doctor should have reviewed her, and given her a CT scan or arranged for her to stay in hospital overnight for observation. The hospital also did not to check whether there was anyone at her home, or give her advice about what to do if she suffered certain symptoms.

The hospital put Miss A through a frightening experience as a result of the failings in its care.

We partly upheld the complaint.

Putting it right

The hospital apologised to Miss A for its failings and for her frightening experience. It also agreed to prepare an action plan to learn lessons from the failings we identified.