Failures in investigation of woman's death

What happened

Mrs Y was initially treated on an acute medical unit (the unit) and was then transferred to a ward later the same day. At some time between 4am and 5am the following morning, Mrs Y left her bed. She was found dead at 5.15am.

Her daughter, Mrs A said lack of care by the Trust meant that her mother was able to leave her bed and die prematurely.

What we found

The Trust had already properly explained what happened in relation to some aspects of Mrs A's complaint and had already acknowledged that key assessments ? falls risk assessment and bed rails assessment ? were not completed as they should have been. It had introduced changes as a result. However, it needed to do more to make sure that changes were monitored and improvements were maintained.

We were unable to say whether completion of these key assessments would have prevented Mrs Y from leaving her bed.

The Trust's investigation did not take statements from all staff at an early stage and this led to information being lost which could have helped Mrs A to understand what had happened to her mother. We also found the Trust did not keep Mrs A informed of delays in its investigation and gave her wrong information on one occasion.

Putting it right

The Trust apologised to Mrs A that statements were not taken from staff as soon as possible after events occurred, and for the failings in complaint handling. It paid her £250 compensation and told her what action it had taken to make sure records are properly completed and how compliance would be monitored.