GLASGOW’S health board has been asked to apologise after a "very disorientated" patient fell out of bed and fractured their hip.
A relative of the patient complained that NHS Greater Glasgow and Clyde “failed to provide appropriate care for their parent” after they fell from their bed, while bed rails were in place, and fractured their hip.
They said that staff had been made aware that their parent was confused and “very disorientated” at the time.
The recent complaint to the Scottish Public Services Ombudsman (SPSO) was upheld.
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A report revealed that the SPSO asked the health board to provide an explanation as to how the patient was able to fall from the bed if bed rails were in place.
The information provided showed that they had been found trying to get out of bed on two previous occasions.
The SPSO said: “This led us to question what interventions were put in place to try and prevent a fall from happening and why this appears not to have been successful.
“We found that the lack of a proper assessment of the patient’s mental capacity and their previous attempts to climb out of bed contributed to the fall incident and that this was a significant oversight.
“Additionally, we found that the board failed to maintain accurate and appropriate records, particularly in relation to the 4AT (Rapid Clinical Test for Delirium Detection), on the two occasions that the patient was found trying to get out of bed, and the fall itself.”
The SPSO asked the board to apologise for their failings.
They also recommended some changes to “put things right in the future”. These are:
- Patient records should be accurately completed, signed, and dated with the appropriate level of information included, in accordance with the relevant nursing and midwifery standards.
- Patients should be appropriately reassessed when there is a change in their behaviour and, if bed rails are in use, consideration given to carrying out a reassessment of their use.
- Patients over 65 should be assessed in line with the board’s admission procedures including a 4AT so that a full assessment of the patient risk is achieved.
The board has been asked to send evidence that the recommendations have been implemented.
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A spokesperson for NHS GGC said: “We recognise the issues highlighted in relation to the care of this patient.
“We’re sorry for any distress caused and can confirm we have been in contact with the patient and their family to apologise directly and offer support.
“The ombudsman’s recommendations have been discussed by the multi-disciplinary team and actions have been implemented to ensure lessons are learned from this case and shared with appropriate staff.”
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