The Trust admitted Mrs A onto an unsuitable ward before she passed away
13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
14. Prior to her death, Mr A told us his wife was admitted onto an unsuitable ward with patients with dementia. He explained that the ward she was admitted to looked ‘like a mortuary’ as there were mattresses on the floor. Mr A told us his wife should never have been on a ward with patients with dementia as she was not diagnosed with dementia herself.
15. The Trust says that patients with dementia are admitted across many wards as the hospital does not have a separate ward to specifically place patients with a dementia diagnosis. The Trust has acknowledged and apologised that the ward would have been noisy.
16. The Trust explained where there is a risk of fall, patients are nursed on a mattress which is laid on the floor, to prevent the patient falling from height and causing further injury.
17. Guidance on the use of bed rails says ‘alternatives to bed rails may be considered, such as ultra ‘low height’ beds that minimise the risk of fall injuries’.
18. We do not consider the Trust did anything wrong in placing Mrs A on a ward with some patients who had dementia. There is no requirement to separate patients with dementia from other patients and the hospital does not have a specific ward for patients with dementia.
19. We also consider the Trust’s explanation with regards to mattresses being on the ground to be in line with the Regulatory Agency guidance. Therefore, we have decided to take no further action on this part of the complaint.
20. We recognise Mr A and Miss A’s account, and that seeing Mrs A on a ward they viewed as less than suitable would have been difficult.
Staff did not provide Heimlich manoeuvre
21. Mr A and Miss A complain the Trust did not provide the Heimlich manoeuvre on Mrs A, when she was unwell. They told us they believe that Mrs A would still be alive if the Trust had provided this manoeuvre.
22. Mr A and Miss A have not yet completed the organisation’s complaints process for this part of their complaint.
23. It is our assessment that Mr A and Miss A should go back to the Trust for a response regarding this issue. Mr A and Miss A told us this was an important part of their complaint, as they believe that if Mrs A had received the Heimlich manoeuvre from staff, it could have saved her life. We have not seen any clear reason that would prevent Mr A and Miss A from returning to the Trust to pursue this complaint.
24. It is important the Trust has the chance to look at the complaint and give a response. We have therefore decided to take no further action at this time.
25. If Mr A and Miss A remain dissatisfied after they have completed the Trust’s complaints process, they can bring the complaint back to us.
26. If they wish to bring the complaint back to us, they should do so as quickly as possible. This is because we have a legal time limit of one year from the day a person became aware of their reason to complain. We can decide to set this aside if there is strong reason to do so, and we will consider the amount of time the complaints process took.
27. We offer our condolences to Mr A and Miss A for their difficult experience and the loss of Mrs A. We hope this statement will help them understand how we reached our decision.