Clinical treatment in hospital: Aneurin Bevan University Health Board

The Ombudsman investigated a complaint from Ms A about the care and treatment provided to her grandmother, Mrs B, by the Health Board, following her admission to hospital on 23 August 2021. The investigation focussed specifically on whether Mrs B was appropriately assessed, and her level of vulnerability documented, the failure to carry out a falls risk assessment and whether this resulted in Mrs B sustaining a fractured risk following a fall. The investigation also considered whether appropriate measures were put in place following Mrs B’s fall and whether her medical records were maintained to an appropriate standard.

The Ombudsman found that there was a clear failure to recognise Mrs B as vulnerable and there was a failure to carry out a falls risk assessment. Whilst it was not possible to determine for certain whether Mrs B would not have fallen and sustained the injuries that she did, had her vulnerabilities been fully recognised and the risk assessment completed, the element of uncertainty about this issue, and whether it would have changed the course of events for Mrs B, constituted an injustice to Mrs B and her family. The Ombudsman upheld the complaint.

The Ombudsman found that there was a failure to complete an enhanced care assessment correctly following Mrs B’s fall. However, as there was no evidence that Mrs B suffered any harm or injustice as a consequence of the service failure. The complaint was not upheld.

The investigation found that record keeping fell below an adequate standard in respect of Mrs B’s clinical records. This included the failure to complete a falls risk assessment and a failure to document the special visiting arrangements put in place for Mrs B. As a consequence, Mrs B’s family members were denied visiting access, causing both distress to them and to Mrs B. This service failure represented an injustice to both Mrs B and her family. The Ombudsman upheld the complaint.

In addition to action taken by the Health Board prior to the conclusion of the investigation, it agreed to provide Ms A with a written apology for the failings identified, to provide a reminder to all staff about the importance of fully and accurately recording information provided by patients and their relatives on admission and acting on that information, and incorporate into its audit of nursing documentation a check for the completion of the “This is Me” booklet.