The Ombudsman investigated Mrs A’s complaint about whether the nursing care her mother, Mrs B, received at South Pembrokeshire Hospital Community Hospital following a fall on 10 January 2024, up until she was admitted to the Emergency Department (“ED”) at Withybush Hospital (“the Hospital”) on 25 January, was timely and met the appropriate standard.
Overall, the investigation found that no failings with the provision of wound care, pain relief, patient observations, basic nursing care and falls prevention. The investigation found that Mrs B’s symptom of breathlessness was escalated to medical staff and appropriate actions taken. Accordingly, Mrs A’s complaint was not upheld.
Whilst not within the timeline of the investigation, the investigation found that the bed rails assessments, were not in line with the Health Board’s policy (to assess twice a day) and did not document the decision making and rationale for their use between prior to Mrs B’s fall on 10 January 2024.
The Ombudsman invited the Health Board to consider reminding relevant staff of the Health Board’s policy on bed rail assessment and that bed rail assessments are completed twice a day, in line with Health Board policy. Also to ensure that the decision to use, or not to use, bed rails is clearly documented and that if the patient has the capacity to make decisions regarding the use of bed rails, their decision is respected and documented in line with nursing standards.