Mr D's wife complained about the care her husband received after a fall at home. She believed her husband died as a direct result of the poor care he received in hospital. She was extremely distressed by the possibility that his death could have been avoided.
Mr D had a fall at home. He sustained a severe head injury and was admitted to intensive care.
Mr D was later transferred to a ward. While on the ward he fell out of bed when staff were changing his bedding. His condition deteriorated and he died later the same day.
What we found
We partly upheld this complaint. No vital signs observations were carried out after Mr D's transfer from intensive care to the ward. The Trust did not follow the correct protocol when handling Mr D during the bedding change, and then failed to follow its own falls policy after he fell out of bed. In addition Mr D was left alone for a period of time during which he should have had one-to-one care. We did not see any evidence that these failings resulted in Mr D's death or that his death was avoidable.
Putting it right
The Trust acknowledged and apologised to Mrs D for its failings. At our recommendation it produced plans to make sure observations are carried out and recorded in line with national guidelines.
County Durham and Darlington NHS Foundation Trust
County Durham
Delayed replying to complaint
Apology
Recommendation to learn lessons or draw up an action plan