Mrs T’s fall
21. Mr T complains that on 13 September 2018, the Trust failed to follow the falls risk assessment completed for his mother, Mrs T. He says the Trust did not consider his mother’s eyesight and balance that had been affected by a stroke she had on 12 September and put her in a private room.
22. In the Trust’s complaint response dated 16 May 2019, it said there are a number of different assessments that take place when a person is admitted to hospital, and these are done by the multidisciplinary team (MDT). MDTs are formed of health and care professionals working together to support people with complex needs. From a nursing perspective the assessments performed on admission are: • falls assessment • waterlow – to assess skin integrity and risk factors of pressure damage • bed rail assessment – to assess if appropriate to use or a further risk • manual handling – is any equipment and/or assistance required • nutrition.
23. The Trust said all these nursing assessments were performed on Mrs T on her admission on 12 September. It explained the falls assessment includes a section on visual impairment and decreased confidence. It said Mrs T was assessed as being at risk of falls and was commenced on a two to four hourly comfort round where a healthcare professional (HCP) checks if a patient is comfortable. It said comfort rounds were completed every two to four hours.
24. Mrs T was assessed as requiring assistance to mobilise due to her visual impairment and said she was encouraged to use the call bell, which was in reach, and further explained she was also provided with non-slip socks.
25. It explained that a physiotherapist (PT) assessed Mrs T on 13 September who checked her vision, hearing, co-ordination and proprioception (sense of self movement and body position). The Trust said the physiotherapist documented Mrs T was able to visually track her and was also able to perform the co-ordination test. It said Mrs T was able to roll on to the bed, sit from lying down, sit to stand and move around the room with a stick. In addition, Mrs T was discharged from the physiotherapist on the same day with a recommendation that she receive continued assessment from occupational therapy (OT).
26. The Trust said the doctor who initially assessed Mrs T after she was transferred to the acute stroke unit (ASU) from ophthalmology, documented she was at risk of falls and recommended she was moved to a main bay. Unfortunately, at that time there were no beds available in a main bay and there were no patients who were less at risk of falls to swap with. In Mrs T’s case, based on the physiotherapy and OT assessments, other patients were deemed at a higher risk of falls and she had to remain in the side room. It said Mrs T was in an appropriate bed given her increased risk of falls and there was no identified option to create a bed space in the main bay. The Trust apologised Mrs T was placed at increased risk by being in a side room. Ward management of side rooms is not a stand-alone assessment and is continued on a 24-hour basis.
27. To help us consider this complaint we sought the advice of a nurse (our nurse adviser).
28. The relevant guidance is NICE [CG161]: Falls in older people: assessing risk and prevention, 2013. This says healthcare professionals should consider all patients aged 65 and over as at risk of falls. Falls interventions should: • ‘promptly address the patient's identified individual risk factors for falling in hospital and • take into account whether the risk factors can be treated, improved or managed during the patient's expected stay.’
29. The medical evidence shows the Trust admitted Mrs T not due to a fall, but with a stroke. It is recorded she had not fallen within the previous 12 months. However, she had suffered a stroke which caused a sudden loss of vision. This was improving but was still impaired on admission to the ward on 12 September 2018.
30. Our nurse adviser said although there is no specific falls care plan recorded within the medical records, Mrs T was on the stroke pathway and therefore her individual risk factors were considered, as evidenced within the medical records. The conclusion was she was at increased risk of falls due to her decreased vision.
31. Mrs T had assessments from the occupational therapist (OT) and PT on 12 and 13 September 2018, because she was on the stroke pathway. This included a performance profile which assessed her abilities pre-admission and on admission. These assessments cover all activities of daily living, including mobility.
32. We considered whether the Trust took into account the impact the stroke may have had on Mrs T’s eyesight and balance, in line with clinical standards and guidance. The relevant guidance is the Romberg Test for Imbalance. This test measures a person’s sense of balance. It is typically used to diagnose problems with the inner ear, and position sense during a neurological examination.
33. The medical records show Mrs T’s balance was assessed by OT. It is recorded within her notes she was steady on her feet and ‘Romberg’s negative’ is documented within the medical records. A Romberg test is negative if the person has minimal swaying during the test. It also means they are able to stay stable with their eyes closed or open.
34. The PT documented Mrs T was independent following assessment. However, they concluded that visual changes could affect activities of daily living (ADL). The plan was for her to be seen by OT whilst she was in hospital.
35. Our nurse adviser said the OT and PT concluded that Mrs T’s eyesight would impact on her abilities to perform her activities of daily living and following medical assessment, the conclusion was that she should be moved to an open bay due to an increased falls risk secondary to reduced vision. Her balance was assessed, and no deficits were found. The impact her reduced vision may have on her falls risk was considered, in line with Romberg’s Test and NICE guidelines.
36. In light of the assessments, we considered whether the Trust took appropriate action to minimise the risk of a fall, in line with clinical guidance.
37. Patients at risk of falls should have interventions implemented that address their individual risks identified during assessment. NICE guidance: Falls in older people: Assessing risk and prevention says: ‘Ensure that aspects of the inpatient environment (including flooring, lighting, furniture and fittings such as hand holds) that could affect patient’s risk of falling are systematically identified and addressed.
Ensure that any multifactorial intervention: • promptly addresses the patient's identified individual risk factors for falling in hospital and • takes into account whether the risk factors can be treated, improved or managed during the patient's expected stay.’
38. Our nurse adviser said Mrs T’s risks were related to her impaired vision. Despite the conclusion that Mrs T should be moved to an open bay where she could be observed more frequently, this did not happen.
39. The Trust has explained that Mrs T could not be moved to an open bay due to the enhanced needs of other patients. The medical records show she was on three hourly checks. However, our nurse adviser said more could have been done to reduce her risks, especially overnight. For example, there was no falls care plan or multifactorial interventions within her records. Multifactorial intervention is an intervention with multiple components that aims to address the risk factors for falling.
40. We note there was also no documented discussion with Mrs T regarding the use of the call bell overnight. In the Trust’s incident report, it said her side room light was not on at the time she fell, when the room was becoming darker. Given her reduced vision and the dimmed lighting, she should have been encouraged to use the call bell for support in assisting her to and from the toilet. It is also not clear if the doors to the side room were open. This should have been discussed with her as it would have allowed for brief observation on passing the room.
41. Mr T is concerned whether the Trust followed its risk assessment for his mother, considered how the stroke affected her balance and whether it should have placed her in a side room. We have carefully considered the relevant evidence, including clinical advice. Mrs T had assessments from an OT and PT as part of the stroke pathway during her admission. These assessments identified she was at increased risk of falls due to her decreased vision. The medical records show Mrs T’s balance was assessed. Based on the evidence, we see the Trust did consider how Mrs T’s stroke affected her eyesight and balance in line with NICE and Romberg’s guidelines.
42. The Trust’s assessments concluded that Mrs T should be moved to an open bay due to an increased falls risk secondary to reduced vision. The Trust said it was unable to move Mrs T to an open bay, as they were full. There were no patients to swap with, as other patients were deemed at a higher risk of falls. We recognise the difficulties the Trust faces when prioritising patients and we therefore cannot be critical of the Trust if there were no beds available in an open bay. The Trust apologised that Mrs T was placed at increased risk of being in a side room. Because she was placed in a side room with increased risk of falls due to her decreased vision, we consider more consideration should have been given in the Trust’s management of her risks overnight.
43. There is no evidence within the medical records of a falls care plan and therefore no indication of what falls prevention interventions had been put in place, in line with NICE guidelines. It is not documented within the medical records that staff encouraged Mrs T to use the call bell overnight when lighting was dimmed, despite her visual impairment, and she was not asked if the door to her side room could be opened overnight. Mrs T did have capacity and she should have been asked to use the call bell for assistance and whether she wanted the door leaving open. This is a failing.
Impact
44. Having seen evidence of a failing, we next looked at whether this had a negative impact on Mrs T, and, if so, whether the Trust has put things right. We do not normally uphold complaints where we find that appropriate action has been taken to put things right or if we cannot link the impact to the failing.
45. Whilst in the side room Mrs T fell, banging her head on a wash basin, and breaking her hip. Mr T says his mother’s fall could and should have been avoided and it triggered the start of her physical and mental health deterioration, causing her to move into a nursing home. He says she would still be alive had she not fallen.
46. Although we saw no evidence of a specific falls care plan in her records to address and mitigate the risk of a fall, Mrs T was on the stroke pathway and we saw evidence of her individual risk factors being considered.
47. Mrs T suffered a hip fracture from her fall. Our nurse adviser said it is not possible to say the fall would have been prevented even if a falls care plan was in place. Royal College of Physicians Audit Report 2015 explained that 95% of all falls are unwitnessed and research has shown that multiple interventions performed by multidisciplinary teams (MDT’s) and tailored to individual patients can reduce falls by 20-30% but cannot prevent them.
48. On balance therefore, we cannot say it is more likely than not that Mrs T’s fall could have been prevented, had the Trust completed a falls care plan. However, what we can say is that had the Trust completed a falls care plan and given more consideration to the management of her risks overnight, it could have reduced the chances of Mrs T falling. We recognise that not knowing if Mrs T’s fall could have been prevented is distressing for the family and this may be disappointing for them to learn.
49. We are sorry to learn of Mrs T’s health deterioration, her having to move into a care home and her sad death in March 2020. Having carefully considered the relevant evidence and clinical advice, it is not possible to directly link the fall, and the affects Mr T says this had on his mother, to the failings we have identified. This is partly because, we could never say her fall would have been completely prevented, even if the Trust had completed a falls care plan. And partly due to the length of time between her fall, her admission to a nursing home (six months after her fall) and sadly dying (18 months after her fall). As a result, because of the many factors which could have contributed to Mrs T’s deterioration in health, we are unable to say it was a direct result of the failings by the Trust.
50. We have gone onto consider what actions the Trust has taken as a result of this part of the complaint.
Outcome:
51. Based on our Principles for Remedy, where there have been failings leading to an injustice, the public organisation should try to offer a remedy that returns the complainant to the position they would have been in, if the failings had not happened.
52. An appropriate range of remedies will include: • an apology, explanation and acknowledgement of responsibility • remedial action, i.e. service improvements to minimise the risk of this happening again • financial redress.
53. As an outcome to the complaint, Mr T is seeking an apology, an acknowledgement of failings, service improvements and a financial remedy.
54. There is no evidence the Trust has acknowledged there was a lack of falls interventions or care plan for Mrs T or apologised for the distress caused. We will go on to consider this further within our recommendations later within this report.
55. As a result of Mrs T’s fall, the Trust has put in place the following: • ‘staff involved in completing reflection about the incident. All ward staff to receive update training for post falls care and procedure, via the ward falls champion • staff reminded at safety briefing to ensure lighting provided to all ward areas • liaison with patient safety regarding fall and identified learning sessions to be delivered by ward falls champion • post falls prompt cards for ward computers to remind staff of the post falls procedure.’
56. As the lack of falls interventions or care plan has not been identified by the Trust, there has been no learning identified to address this specific issue. However, it is noted that training for falls prevention and interventions has been implemented by the Trust. Although we are pleased to see the actions taken by the Trust, we consider more should be done. We consider the Trust should acknowledge the failings and apologise for the distress caused. We are of the view the Trust should ensure (if not already done so) the falls prevention and interventions training has been given to the staff who were involved in Mrs T’s care prior to her fall.
57. Mr T has requested a financial remedy. Based on our Principles for Remedy and our guidance on financial remedy, we consider financial redress is appropriate for the distress caused. We have gone onto consider this in our recommendations section at the end of this report.
Delay in informing family regarding fall
58. Mr T complains the Trust did not inform the family their mother had fallen until the next morning.
59. The Trust said Mrs T fell at 7.25pm on 13 September. It explained the family were not informed until the following day and acknowledged this was an error. It apologised her family was not given the opportunity to be with Mrs T at the time. This has been discussed with relevant staff to minimise the risk of this happening again.
60. The Trust’s incident report acknowledged Mrs T’s relatives were not informed of the fall at the time or overnight. Mrs T was also not consulted about informing her relatives. The ward sister spoke to Mrs T on 14 September at 11am and apologised to her because her relatives had not been informed of the fall. Mrs T’s relatives were contacted at 11.15am and told of the incident and a verbal apology was given. The ward sister also met with Mrs T’s family when they attended the ward to visit, and a further verbal apology offered. This is also confirmed within Mr T’s supporting information.
61. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20: Duty of Candour, says: ‘As soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred a registered person must— a. notify the relevant person that the incident has occurred in accordance with paragraph (3), and b. provide reasonable support to the relevant person in relation to the incident, including when giving such notification.’
62. Nursing and Midwifery Council: The Code says: ‘5.5 share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand.’
63. We consider the Trust’s delay in telling Mrs T’s family about her fall was not in line with the duty of candour and NMC guidance. This is a failing by the Trust.
Impact:
64. We acknowledge this caused Mrs T’s family further distress and disappointment, especially during an already difficulty time.
Outcome
65. As an outcome to the complaint, Mr T is seeking an apology, an acknowledgement of failings, service improvements and a financial remedy.
66. We are pleased to see the Trust has acknowledged this failing and apologised, both verbally and in writing for the distress caused.
67. Insofar as service improvements, the Trust has discussed with staff about the need to inform patients’ relatives in a timely manner. It has also been discussed at safety briefings about duty of candour and the individual member of staffs’ responsibility to inform patients next of kin.
68. Although we are pleased to see the Trust has acknowledged this failing, apologised for the distress caused and put in place service improvements, we consider a financial remedy is appropriate in line with our Principles for Remedy. We will consider this within our recommendations.
Post falls review
69. Mr T complains the Trust did not send the family an appropriate post-falls report.
70. On 14 September 2018, Mr T and his sister said the Trust’s ward sister spoke to them at the hospital and apologised for their mother falling and that no-one called them to let them know until the day after. They said the ward sister explained there would be a full investigation into the fall and they would receive copies of the paperwork.
71. On 19 September, the Trust carried out an investigation into Mrs T’s fall on 13 September, using its Falls Incident Investigation Tool. The findings were presented to the Trust’s Falls Panel on 27 November.
72. On 29 November, the Trust sent a letter to Mrs T. This explained that a falls assessment was completed on admission on 12 September and identified her as a falls risk due to her visual impairment. The following day it said a physiotherapy assessment identified her as independently mobile and discharged her from their care. It apologised she sustained a fall whilst an inpatient but did not feel the fall was avoidable and any intervention would not have prevented the fall occurring.
73. The relevant guidance is: • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20: Duty of Candour, says:
‘The notification to be given under paragraph (2)(a) must— a. Be given in person by one or more representation of the health service body, b. provide an account, which to the best of the registered person's knowledge is true, of all the facts the registered person knows about the incident as at the date of the notification, c. advise the relevant person what further enquiries into the incident the registered person believes are appropriate, d. include an apology, and e. be recorded in a written record which is kept securely by the registered person.
The notification given under paragraph (2)(a) must be followed by a written notification given or sent to the relevant person containing— a. the information provided under paragraph (3)(b), b. details of any enquiries to be undertaken in accordance with paragraph (3)(c), c. the results of any further enquiries into the incident, and d. an apology.’
• PHSO: Principles of Good Complaint Handling says:
‘Be open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations, and reasons for their decisions… Investigate complaints thoroughly and fairly, basing their decisions on the available facts and evidence.’
74. Our nurse adviser considered the falls report, which was the basis of the letter sent to Mrs T in November, should have reached the conclusion Mrs T’s individual risk factors did not lead to a falls care plan, and therefore individualised interventions to reduce the risk of falls were not documented. Given her impaired vision, there should have been more consideration of managing her risks overnight when the lights were dimmed. Mrs T did have capacity and should have been asked to use the call bell for assistance.
75. The fall report also identified that Mrs T’s family were not told of the fall until the day later, however there was no acknowledgement of this within the November letter or an apology. The fall report said Mrs T’s side room light was not put on at the time she fell, the room was becoming darker, again, this was not mentioned in the letter.
76. Therefore, we are of the view the findings of the Trust’s investigation were not line with NICE guidance: Falls in older people and our Principles of Good Complaint Handling. We consider the November letter did not provide sufficient information from the falls report, in line with the duty of candour. This is a further failing.
Impact
We acknowledge this caused further distress for the family.
Outcome
77. There is no evidence the Trust has acknowledged the initial investigation into Mrs T’s fall and subsequent letter in November 2018 was not in line with relevant guidance and standards or apologised for the distress caused. We will go onto consider this further within our recommendations later within this report.
78. Mr T has requested a financial remedy. Based on our Principles for Remedy and our guidance on financial remedy, we consider financial redress is appropriate for the impact caused. We have also gone onto consider this in our recommendations.
Knowledge of medical history
79. Mr T complains when the Trust advised his mother she needed an operation to treat her broken hip, the consultants involved in her care were unaware of her existing medical conditions, which included her recent treatment for cancer in May/June 2018, her level of COPD, and her recent stroke.
80. We have not been able to establish if this issue has been considered during the local resolution process. Taking into account the length of time the complaint was with the Trust and us, we consider it customer focused to address this issue within our investigation.
81. To help us in our consideration of this complaint, we sought advice from a consultant orthopaedic surgeon (our orthopaedic adviser).
82. The relevant guidance is: • NICE [CG124]: Hip fracture: management, 2011. This says: ‘1.8.1 From admission, offer patients a formal, acute, orthogeriatric or orthopaedic ward-based Hip Fracture Programme 1.8.2 If a hip fracture complicates or precipitates a terminal illness, the multidisciplinary team should still consider the role of surgery as part of a palliative care approach.’
• GMC: Good medical practice, 2013. This says: ‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a. adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient.’
83. The medical notes record the orthopaedic surgeon was aware Mrs T was at high risk for surgery. Although the note does not record the details of why she was at high risk, the orthopaedic surgeon and their team would have had access to her medical notes (including her medical history). It is therefore more than likely they were aware of her medical history (i.e. cancerous tumour, heart failure, COPD and recently having a stroke) prior to the operation.
84. In line with NICE: Hip fracture guidance, the management plan would have involved a multidisciplinary approach, involving a number of different clinical specialists, including a surgeon and an anaesthetist etc. It is very unlikely the MDT would not have carefully considered Mrs T’s present condition and medical history prior to surgery.
85. The medical notes show that a junior doctor spoke to the family the day after the fall. They indicated Mrs T may need surgery as a result of her fracture. It is recorded the family was concerned she was unable to have surgery before for her lung cancer tumour due to her comorbidities, and therefore whether she was able to have this surgery. The family wanted to be present at the hospital to speak with the orthopaedic team. The medical evidence and the family diary provided by Mr T demonstrates the clinicians, including those from the orthopaedic team, spoke to the family and Mrs T about the operation and Mrs T’s wishes on 14 September 2018.
86. We understand Mr T questioning whether the consultants involved in his mother’s care were unaware of her existing medical conditions. The medical records show Mrs T’s previous medical history. The relevant clinicians would have had access to these records before her operation. Her family also spoke to the clinicians about her history prior to the operation which was taken into account. Considering all relevant information, we are of the view it is therefore more likely than not that the clinicians involved in Mrs T’s hip operation were aware of her medical history prior to the operation, in line with NICE and GMC guidance.