National Ombudsmen
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Vulnerable elderly woman suffers severe facial bruising in hospital that failed her

A woman in her 90s suffered serious bruising to her face just before she died after falling in hospital, a Parliamentary and Health Service Ombudsman investigation found.

The vulnerable partially sighted lady was admitted to University Hospital Southampton NHS Trust with a chest infection and was in a confused state after she left her nursing home. She suffered severe bruising to her face when she fell out of bed, into a gap between the wall and bed, when an agency health care assistant was changing her bedding.

The Parliamentary and Health Service Ombudsman's investigation found that according to the Falls Care Plan – a plan to manage the risk of the patient falling - she should be moved by two members of staff but she was moved by only one.

The hospital did not tell the woman's daughter about the fall. When her daughter saw her mum in the nursing home she was shocked and distressed to see the bruising on her face. The hospital also did not record the mother's injuries in her hospital discharge paperwork.

The hospital then failed to tell the daughter that her mum had been discharged from hospital to a nursing home.

The hospital also provided incorrect information to the daughter about funding arrangements.

The mother died five days after being discharged to the nursing home. The daughter told the Ombudsman Service her mum's bruising is an enduring memory of her.

Parliamentary and Health Service Ombudsman Julie Mellor said:

'This story shows the importance of following clearly laid care plans. It also highlights the effect poor communication in the health service can have on people.

'The daughter, on several occasions, was left not knowing what was happening to her incredibly vulnerable mother, which was clearly very distressing for her. The Trust's poor treatment of her mother has meant she has lost confidence in the NHS.

'We have asked the Trust to apologise to the daughter for failing to take enough action in relation to her mother's fall out of bed and to produce an action plan that demonstrates it has learnt the lessons from this case, in particular in relation to staff following Falls Care Plans.'

The woman's daughter said:

'I was shaken and shocked when I saw my mum at the nursing home. I still get flashbacks. The staff at the nursing home were on the verge of tears. How can this happen, in 2013, to a 95-year-old lady?

'I was not happy with the care she was receiving at the hospital and it took forever to get her discharged. In the end, when they eventually did discharge her, they didn't even tell me.

'I'm terrified going into a hospital – I think they are incompetent. What was lacking was basic nursing, basic common sense – this was sorely lacking.'

The Ombudsman Service has found evidence the Trust has taken steps to address the failings. They have introduced electronic incident reporting, use ward meetings to tell staff about informing relatives when patients fall, discuss discharge completion summaries at governance meetings and audit discharge checklists.

The Parliamentary and Health Service Ombudsman is independent and impartially investigates complaints from individuals about UK government departments, and other public organisations, and the NHS in England. It carries out adjudications making final decisions on people's complaints. The Ombudsman Service investigates 4,000 cases a year and upholds around 42 per cent.

 

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