A BREAKDOWN in communication between staff has resulted in the death of a patient at Forth Valley Royal Hospital, the ombudsman ruled.

The Scottish Public Services Ombudsman (SPSO) has upheld a complaint against NHS Forth Valley in a decision report published last month.

The health board has issued an apology to the patient's family and guidelines have been updated to prevent further tragic incidents from taking place.

According to the report into the complaint, the patient was admitted to the hospital in Larbert after they suffered a stroke.

The patient, identified as "A", also had delirium and a background of dementia.

The ombudsman's report said: "Staff were aware that A had to be supervised and to be accompanied at all times when they were out of bed.

"However, despite being under close observation, a contracted nurse allowed A to remain in the toilet unsupervised and they sustained a fall which resulted in a severe head injury and subsequently A's death."

The complainer, the child of the patient who tragically died, believed that their parent should not have been left unattended and that the fall may have been prevented.

According to the SPSO, staff had carried out a a comprehensive falls risk assessment and it was determined that the patient was not to be left unsupervised.

The report added: "It was felt that A had no awareness regarding the use of the call bell system (a button or cord found in hospitals that patients can use to alert hospital staff of their need for help).

"However, a nurse had stepped out of the toilet to afford A some privacy and A attempted to rise from the toilet unaided and suffered a fall."

Crucially, the report said: "Although the record-keeping regarding the falls risk was completed to a good standard, there was a breakdown in communication between permanent staff and the contracted nurse about the specific level of observation required for A."

The complaint was upheld and recommendations were issued, including that "staff should ensure that when passing information to others that full details of the levels of observation required are understood".

A spokeswoman for NHS Forth Valley told the Advertiser: "We were very sorry to learn of this incident and have formally apologised to the family concerned.

"It was confirmed to the ombudsman that a review of the NHS Forth Valley's 'Nursing Observation and Interventions' guideline had recently been completed and was being rolled out across the whole organisation.

"This provides a framework for nursing staff providing care for patients who require a higher level of observation, ensuring a balance of safety and patient choice."