NHS Fife has apologised for failings in the care given to a patient.
The woman, identified by the Scottish Ombudsman only as Mrs C, had been admitted to hospital suffering from increased confusion and in need of more and more pain relief.
She was on a high dose of steroids for giant cell arteritis, an inflammation of the blood vessels, usually in the head. Mrs C was transferred a month later to another hospital, then back to the first three months after that.
However, her husband complained that she had fallen while in both hospitals and was concerned these events had not been properly investigated.
Mr C also said his wife’s medication was not properly monitored, that the nursing care of her deteriorating condition and pressure ulcer was inadequate and that his complaints were inadequately handled.
The ombudsman took advice from a medical adviser who said Mrs C had a complicated medical history but found she had had an unacceptable number of falls in the first hospital and the assessment of her being at risk of falling was inadequate.
In line with national guidance, staff should have done more to prevent her from falling, and so the ombudsman upheld the complaint that Mrs C was not properly monitored or assessed for this.
He also upheld the issue of complaints handling and said, while the board’s response did address issues raised and explained the reasons behind treatment decisions, it should also have tried to address underlying issues. In addition, the time it took to respond to the complaint was unreasonable, only happening after the ombudsman had started to investigate, nine months later.
Other complaints were not upheld.
The investigation found that, after each of the falls, both hospitals treated Mrs C’s symptoms appropriately. There was also evidence that she was appropriately monitored and assessed for her medication and that she received good personal care from nursing staff and a suitable care plan was implemented to treat the pressure ulcer.
NHS Fife medical director Dr Brian Montgomery said: “We have apologised to the family and accept that aspects of care and complaint handling fell short of the required standards. All recommendations have been actioned and, with the exception of one, are complete. The ombudsman’s office has confirmed their satisfaction with the actions taken by the board.”