At-risk patient fell and broke their hip after Lothian hospital ran out of fall alarms

An at-risk patient fell and broke their hip in hospital after they had run out of fall alarms.

A complaint was received by the Scottish Public Services Ombudsman from the now deceased patient’s child.

It stated that the patient had not received a fall alarm, that reporting the fall had been delayed, and that an assessment had been delayed.

NHS Lothian apologised, saying that there had not been enough alarms to give one to the patient, and more had now been purchased.

They also accepted that a “top to toe” examination should have been carried out and that the broken hip was delayed in being identified.

The watchdog took independent advice from a registered nurse, they found that there was “no evidence” the patient had received timely risk assessments or person-centred care.

It was found that the hospital missed “basic assessments,” including a pain assessment and that despite a misaligned leg, their hip break went unnoticed.

There was also a “failure” to follow correct procedures in pressure ulcer prevention, malnutrition, and wound assessment and management, wound charts were also not completed.

In compiling the report, the Ombudsman also found that the board’s complaint response had not been “open, transparent, and accurate.”

They had failed to identify failings in their treatment, and relevant documents were not provided when initially requested.

Recommendations in the report include that the health board ensure staff are “aware of their responsibilities” in patient care and assessments.

Alison Macdonald, NHS Lothian’s executive nurse director, said: “We would like to publicly repeat our apology to the family for the failings in this case.

“We accept the Ombudsman’s recommendations and have implemented a comprehensive action plan to address each in full and have updated the SPSO accordingly.”