Falls
14. Mrs N believes there were opportunities for staff at the Hospital to prevent three falls her mother had during her admission. She described how upsetting it was to visit her mother after the falls because her face was so swollen. She says her mother’s health declined significantly after the falls to the extent she was unable to have a proper conversation with her.
15. The Nursing Adviser told us a fall is defined as an event which results in a person coming to rest inadvertently on the ground or other lower level. The Falls Guideline says all people over 65 years of age should be considered at risk of falling in hospital. For those at risk there should be a multifactorial assessment. Healthcare professionals should identify the patient’s individual risk factors. They should then intervene to promptly address any of the risk factors.
16. The Trust Policy says a falls risk assessment should be undertaken within one day of admission for every patient. The assessment should be repeated weekly or following a fall or a change in the patient’s condition.
17. Nurses carried out an initial assessment of Mrs E’s falls risk on 28 March 2021. They noted she had a previous history of falls and was unsteady when walking with a stick. The assessment noted Mrs E was supposed to wear hearing aids in both ears but did not wear them.
18. Nurses also completed a form entitled ‘Patient falls assessment and intervention pathway.’ This was a multifactorial assessment and a plan for addressing risk factors.
19. On the morning of 30 March 2021 the clinical records show Mrs E fell and hit her head. Nurses did not witness the fall. Mrs E told them she had been walking and her footwear had not been on fully. She said she slipped onto her right side and hospital staff helped her to bed. A doctor reviewed her that evening a noted she had a swollen jaw and a small scratch above her mouth. They arranged scans. These showed there was no significant head injury, but Mrs E had a fracture to the right side of her pelvis.
20. Mrs E had her second unwitnessed fall on 16 April 2021. She had been trying to get out of bed and fell to the floor. Mrs E said she had hurt her back and one of her shoulders. The doctor on call reviewed her and found no new concerns. They arranged a further scan of Mrs E’s head, which did not show any injuries.
21. Mrs E fell for the third time on 19 April 2021. A nurse found her on the floor. Mrs E said she had been trying to move from a chair to her bed. She said she had pain in her head, neck, and shoulders. Nurses noted there was no evidence of any injury. Doctors reviewed her and found no new concerns.
22. Nurses followed the Falls Guideline and the Trust Policy when they completed a multifactorial assessment on the day of her admission to the Hospital. The assessment noted Mrs E’s individual risk factors included confusion, incontinence, reduced mobility and unsteady gait and medication factors. It made no reference to her history of falls. There was limited reference to any interventions or actions that needed to be put in place to mitigate the risks. The multifactorial assessment was incomplete.
23. The multifactorial assessment noted Mrs E appeared confused. It said she had dementia, but it was controlled. The assessment form suggested several interventions could be used including the use of bed or chair sensors, moving the bed to an area where observation could be increased and considering one to one nursing care. There is no evidence ward staff made any of these interventions.
24. While the multifactorial assessment referred to a bed rails assessment there is no evidence of this in the records we have seen. The Nursing Adviser told us Mrs E would have been at risk of harm from bed rails because she was mobile enough to be climb over them and confused enough to overestimate her abilities. Nurses should have assessed her safety with bed rails in place and there is no evidence they did so. Other clinical records suggest bed rails were in place. Bed rails would have increased the height of any fall from the bed. This meant the failure to assess their safety increased Mrs E’s risk of injury.
25. There is also no evidence nurses reassessed Mrs E’s risk of falling after any of her three falls. There were immediate interventions after each fall, such as medical reviews, scans, neurological and physiological observations. But there is no evidence of a formal reassessment of risk. This was not in line with the Trust Policy.
26. All three of Mrs E’s falls were unwitnessed. The Nursing Adviser said this could have been mitigated by nursing Mrs E in a ‘cohorted bay’ or using one to one nursing. Cohorting is when nurses group patients who have similar issues together for easier observation. The investigation reports suggest there were not enough nurses available to provide closer observation.
27. The first fall appears to have been caused by issues relating to footwear. The multifactorial assessment on 28 March 2021 noted there were no concerns about Mrs E’s footwear. There is no evidence in the records that nurses made any interventions relating to footwear following the fall. The Nursing Adviser said nurses could have arranged for Mrs E to wear non-slip socks to try and prevent any further falls. The records are inconsistent when commenting on Mrs E’s footwear. After her third fall, the nurse who reported the incident suggested Mrs E was wearing non-slip socks at the time. But other nursing records refer to her not wearing non-slip socks.
28. The second fall was due to Mrs E attempting to leave the bed. It is unclear if the bed rails were raised or how high the bed was. If the bed had been lower, this could have reduced the risk of harm sustained when falling from a height. Bed sensors could also have been used to try and reduce the risks of further falls. Again, the circumstances of this fall were not the same as the third fall. We cannot say the third fall would have been prevented if nurses had intervened to reduce the risks.
29. We recognise Mrs N believes staff should have prevented her mother’s falls. The Nursing Adviser told us we cannot be certain the falls could have been prevented. While nurses could have taken steps to reduce the risk of falls, and did not, they could still have happened. Patients can still fall even if they are being regularly observed. Also, the various interventions may not have been suitable for Mrs E. For example, bed sensors can cause distress for patients who are confused.
30. However, on balance, we consider the risk of falls could have been reduced significantly if nurses had followed the relevant standards. An audit by the Royal College of Physicians has shown that multiple interventions by the clinical team that are tailored to the individual can reduce falls by between 20 and 30 percent. The audit recognised this was particularly important for patients with dementia or delirium who are at high risk of falling in hospital.
31. The Medical Adviser told us it was clear Mrs E was frail and had multiple medical problems, most notably Lewy body dementia. People with these combinations of medical problems are precarious and at risk of deterioration. They are usually felt to be entering the last stages of life. Mrs E’s poor oral intake was another indication of this.
32. There were multiple factors that contributed to Mrs E's declining health. The effects of the falls were among these factors, but it would be speculative to try and establish how significant the falls were. It is most likely that her illness would have proceeded in the same way and that her death, from pneumonia, was unavoidable. We can see that the first fall led to a pelvic injury, and this reduced her mobility. This would not have contributed to her death some months later. There is no evidence that Mrs E experienced a significant head injury because of her falls.
33. We find nurses did not follow the Falls Guideline or the Trust Policy when they reviewed Mrs E’s risk of falling. There were insufficient risk assessments, and the initial multifactorial assessment was incomplete. In addition, there is little evidence that appropriate interventions were put in place to reduce falls and no evidence that bed rails were being used safely.
34. We consider the risks of Mrs E falling would have reduced had the failings not happened. We cannot say the falls would have been prevented or that Mrs E’s health would not have worsened. We can see how Mrs N is now left with uncertainty and distress about what might have happened if nurses had followed the relevant standards. This is an ongoing and significant injustice to her.
Investigation
35. Mrs N is unhappy about how the Trust investigated her mother’s falls and says she has been left with unanswered questions. She says it took the Trust so long to investigate that it has not been able to provide a satisfactory response about what happened.
36. The NHS Framework explains how organisations should assess whether there has been a serious incident. It defines a serious incident as acts and omissions that result in unexpected or avoidable injury and result in serious harm. It says investigations must be timely and proportionate. They must also be ‘systems based,’ which involves carrying out a root cause analysis (RCA) to establish what went wrong, how it went wrong and why.
37. The Investigation Policy is based on the NHS Framework. It says when a serious incident has been reported the Trust should offer information and support to the patient or their next of kin. They should give them the opportunity to raise questions they want to have considered within the investigation. The Trust should share the findings of investigations with carers and relatives. It should explain any reasons for delay and provide support to the family by appointing family liaison officers.
38. The Investigation Policy explains how the Trust uses the Datix system to make electronic record of potential incidents. It says the Trust must complete the investigation within a timescale identified at the outset. It says in most cases a final report should be produced within 60 days.
39. The NHS Complaint Standards explain how organisations should investigate complaints thoroughly and fairly. It says staff should respond to complaints at the earliest opportunity and give clear timeframes about how long any investigation is likely to take. They should provide regular updates throughout the process.
40. We can see the Trust considered Mrs E’s first fall to be a serious incident. This meant it should have followed the NHS Framework and the Investigation Policy when investigating that incident. The Trust decided the second and third falls were not serious incidents. Given that only the first fall resulted in Mrs E being injured we consider the Trust was right to take this approach.
41. Mrs N told us the Trust advised her shortly after her mother’s first fall that it would investigate it. She said the member of staff who contacted her said the process should take six to eight weeks. The Trust sent a letter to Mrs N on 1 April 2021. This confirmed it intended to investigate the incident and would write to her with the findings. It did not say in the letter how long the process would take.
42. The Trust’s investigation report was dated 7 December 2021. This was more than eight months after the incident, much longer than the 60 days stated in the Investigation Policy. There is no indication that a timescale for completion was agreed. The Trust has offered no explanation for this delay. The only items of evidence considered were the clinical records and the Datix form completed at the time of the events. There were no interviews with staff or Mrs N. Given the time that had passed it is unlikely staff interviews would have been beneficial at that point. The Trust’s investigation was not carried out in line with the NHS Framework because it was not timely.
43. The Trust’s investigation report noted it was ‘not clear what falls prevention measures were in place or communicated.’ It made no reference to communicating the outcome with Mrs N, despite a section of the report entitled ‘Communication.’ Much of that section was incomplete other than showing that family liaison officers were appointed. However, Mrs N did not have any contact from the family liaison officers until July 2022.
44. The Trust then took until August 2022 to share a copy of the investigation report with Mrs N. It said this was because of ‘COVID workload pressures.’ It is hard to understand why it took eight months to send a copy of the document to Mrs N.
45. The investigation report concluded that it was possible the incident could happen again and that it led to ‘moderate harm.’ It said there should be ‘education about clear falls prevention strategies’ and referred to importance of standing and lying blood pressures. It recommended an action plan which included ‘education around the use of enhanced care tool’ and other recommendations that did not appear directly relevant to the issues that arose in Mrs E’s case. There is no recognition of any specific action that would have reduced Mrs E’s risk of falling.
46. The Trust’s investigators did not explain what the causes of the incident were or explain the lessons learned. There was no systems based approach (RCA). This meant its action plan did not address the potential causes of the incident. In addition, there is no evidence the Trust involved Mrs N in the investigation or that it intended to share the outcome with her. It did not follow the Investigation Policy.
47. When the Trust sent Mrs N the investigation report in August 2022 it offered a meeting to discuss the findings, but Mrs N said she wanted reports into the second and third falls first.
48. On 31 August 2022 the Trust informed Mrs N it would not be investigating the second and third falls because they were not significant enough. Mrs N was unhappy with this. She was concerned that her mother had fallen three times in a short period of time and wanted an explanation. The Trust agreed to seek further information from staff. Mrs N regularly contacted the Trust for updates but by the end of December she had not received any information. On 2 February 2023 Mrs N sent a complaint letter to the Trust.
49. The Trust arranged a meeting with Mrs N and other members of her family on 26 April 2023. In the meeting the Trust’s representatives explained how the COVID-19 pandemic had affected incident and complaint investigations and how the departments were still ‘catching up.’ They also explained what the clinical records said about all three falls. The Trust sent a summary of the meeting to Mrs N on 21 August.
50. The evidence shows there were significant delays in the Trust investigating Mrs E’s second and third falls as complaints. It also shows the Trust failed to keep her properly updated about what was happening. Mrs N made a verbal complaint to the Trust in August 2022 and the Trust failed to investigate the matter until she made a written complaint. The Trust did not respond to the complaint at the earliest opportunity or give clear timeframes. It did not follow the NHS Complaint Standards.
51. We find the Trust did not follow the NHS Framework, the Investigation Policy and the NHS Complaint Standards. We can see how the delays and lack of meaningful updates led to avoidable distress for Mrs N. This was during a time when she was grieving. She was left with unanswered questions until the meeting she attended in April 2023, around two years after the events. At that meeting the Trust’s representatives provided explanations based on the clinical records. Because the investigation report was inadequate, and completed long after the event, we can see how Mrs N has not been reassured by the actions the Trust has taken in relation to her mother’s first fall.