14 February 2019

The Belfast Health and Social Care Trust has apologised to a complainant for the care and treatment her mother received while a patient in the Mater Hospital.
The patient had been admitted to the hospital following a stroke.  She had a fall in a bathroom on the ward and sustained a fractured hip.  She was transferred to the Royal Victoria Hospital for surgery, but sadly died the following day. Her daughter complained that she should not have been left unattended in the bathroom.  She also complained about the Trust’s investigation into the incident.

The Ombudsman obtained all relevant documents, including the Trust’s response to the initial complaint.  Interviews with Trust staff were also carried out, and an independent professional advisor consulted.

After considering the evidence available, the Ombudsman found that it was appropriate for the patient to have been left unattended in the bathroom.  However, she also concluded that the patient was put at risk by nursing staff because they did not ensure she was wearing suitable footwear at the time. 

She was unable to say whether this was a contributing factor in the fall as the patient was unable to communicate and there were no witnesses.
In relation to the Trust’s own investigations into the incident, the Ombudsman found a number of significant failings.  The investigation took far too long, had no independent Chair, and failed to look at the issue of the patient’s footwear.

The Ombudsman also found that the Trust’s own investigation report made incorrect conclusions about the role of ward staff in reporting the incident.  In particular it wrongly stated that ward staff did not escalate the incident, and wrongly concluded that senior management were not aware of it.

In addition to the learning identified by the Trust as a result of this complaint, the Ombudsman also recommended that the Trust take the necessary action to ensure that all relevant ward staff have been involved in falls prevention training or instruction, and in particular to highlight the importance of patients wearing appropriate footwear.

The Trust were also asked to provide a sincere and meaningful written apology to the patient’s daughter for the injustice identified in the report, and to pay her £750 to acknowledge her distress.