NHS Ayrshire and Arran hospital didn't discover cracked ribs for weeks after two falls

A hospital didn’t discover a patient had fractured five ribs until weeks after two falls.

NHS Ayrshire and Arran also didn’t regularly evaluate the risk of falls, and did not appropriately review the patient afterwards, a watchdog investigation has found.

It also said that the risk of pressure ulcers had not been sufficiently managed before or after they had developed.

The Scottish Public Services Ombudsman (SPSO) also determined that the hospital had incorrectly filled out the patient’s documentation, and did not update their power of attorney, who was appointed to make decisions on the patient’s behalf, about important health matters.

After fracturing their ribs in two falls in hospital, and developing pressure ulcers, they contracted pneumonia and died shortly after discharge.

The ombudsman found that the patient’s cracked ribs were not discovered until weeks later, when x-rays and a CT scan showed the injuries.

The health board told the SPSO that the patient was assessed by a doctor after both falls, and pain medication was increased.

The scans were taken weeks after the patient fell due to ongoing pain.

NHS Ayrshire and Arran said that the treatment would have been the same if staff had known of the injury earlier.

The health board also apologised that the patient had developed pressure sores, and acknowledged that on some occasions care rounds were delayed due to clinical pressures.

The patient’s power of attorney was not informed of either fall or of the patient’s pneumonia and deteriorating health.

After taking independent advice from a nurse, the SPSO upheld a complaint against the NHS.

The SPSO made a number of recommendations, including that the health board apologise to the power of attorney for all of its failings.

“We extend our sincere condolences to the family of [the patient] and are deeply sorry that their experience did not reflect the high standards of care we aim to deliver in NHS Ayrshire and Arran,” Jennifer Wilson, executive nurse director for NHS Ayrshire and Arran said.

“The board accepts in full the findings and recommendations of the SPSO and has offered a formal apology to the family.

“Work is already underway to address each of the recommendations, and we are committed to ensuring that the lessons from this report are shared across our organisation.”