NHS Greater Glasgow and Clyde has apologised after a patient in their care fractured their hip when falling out of bed.
The patient was reported to be "very disorientated" at the time of the fall, with staff aware of this.
The patient's child filed a complaint to the Scottish Public Services Ombudsman (SPSPO) which was held up, with NHSGGC asked to apologise to the family.
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The health board was asked to explain how the incident happened, with SPSPO told the patient "had been found trying to get out of bed on two previous occasions".
The report added "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."
NHSGGC was deemed to have not done a "proper assessement" of the patient's mental capacity, which was described as a "significant oversight".
The decision reads: "We found that the lack of a proper assessment of A’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
As well as requesting an apology to the patient and their family, the board asked for the following other measures to be implemented:
- 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 bedrails 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.
A spokesperson for NHS Greater Glasgow and Clyde 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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